Program Policies & Procedures

Table of Contents
I.	Buffalo River Services, Inc. Professional Support Services – All Programs
Administration	5
Admissions, Discharges, and Transfers	7
Basic Agency Functions	8
Infectious and Hazardous Waste	11
Records and Reports	12
Consumer Rights	13
Health Care Decision Making	13
Medical Information Disclosure Notice	19
Your Rights With Respect to Health Information About You	25
Complaints	29
II.	Historical Program Policies and Procedures

Section 1: Introduction
Introduction ………………………………………………………………………………………….........…..	
30	
Principles for the Agency …………………………………………………………………………............	31	
Goals …………………………………………………………………………………………………….............	32	
Philosophy ……………………………………………………………………………………………..........….	32	
Mission Statement ………………………………………………………………………………........…......	33	
Vision Statement ………………………………………………………………………………….........…....
.
Section 2: Program Services	33	
Policy #101	Advocacy ………………………………………………………………………….............	34	
	Description of Services ………………………………………………………............	35	
Policy #102	Records ……………………………………………………………………………............	38	
Policy #103	Admission ………………………………………………………………………...............	39	
	Admission Check List ………………………………………………………….............	42	
Policy #104	Assessments ……………………………………………………………………..............	44	
Policy #105	Schedule of Fees ……………………………………………………………….............	44	
Policy #106	Supervision ……………………………………………………………………….............	44	
Policy #107	House Selection ………………………………………………………………...............	45	
Policy #108	Pets ……………………………………………………………………………...........……..	46	
Policy #109	Transportation ………………………………………………………………...........…...	46	
Policy #110	Accounting for Personal Funds ...……………………………………...........…....	48	
Policy #111	Residential and Supported Living Person Supported Funds .…...........….	52	
Policy #112	Waiting List ……………………………………………………………………….............	54	
Policy #113	Respite Services …………………………………………………………….........….….	55	
Policy #114	Discharge …………………………………………………………………….........….…...	55	
Policy #115	Health Care Requirements ……………………………………………..........….…..	56	
Policy #116	Protection From Harm ………………………………………………..........………….	58	
Policy #117	Reportable Event Management ……………………………………..........….…….	60	
Policy #118	Community Transition Services ……………………………………………............	62	

Policy #119	Assisting Supported Person Financially on Away Vacation ..........……....	63	
Policy #120	Scholarship ………………………………………………………………..........…………	64	
Policy #121	Supported Employment/Vocational Services …………………..........………..	65	
Section 3: Support Plans	
Policy #101	Person Centered Support Plan ……………………………………………………..........…..	65	
Policy #102	Independent Support Coordination/DDA Case Management ..........…..	66	
Policy #103	Behavior Support Plan …………………………………………………..........……...	67	
Policy #104	Behavior Support Plan Review and Approval …………………..........……….	68	
Policy #105	Individual Crisis Plan …………………………………………………..........…………	69	
Policy #106	Services Implementation …………………………………………..........……………	70	
Section 4: Medication
Policy #101	Medication Administration by Unlicensed Personnel	71
I.	Medication Prohibitions	72
II.	Self-Administration	72
III.	Staff Requirements ....................................................................,. 73
IV.	Program Requirements	73
V.	Documentation on the Medication Administration Record (MAR)	74
VI.	Editing Medication Administration Records (MARs)	80
VII.	Documentation of Controlled Substances	80
VIII.	Medication Refusal	81
IX.	Leaves of Absence (LOAs)	81
X.	Medication Errors/Omissions Reporting, Management, and Tracking	82
XI.	Technical Assistance/Emergency Protocol	84
XII.	Medication DPCSPosal	86
XIII.	Medication Storage and Labeling	87
IX. Security	88
Policy #102	Medication Administration Code red Status	89
Policy #103	Psychotropic Medication Administration	91
Policy #104	Informed Consent	91
Letter of Approval from State of Tennessee	92
Section 5: Behavior and Crisis Intervention
Policy #101	Use of Positive Approaches	93
Policy #102	Individual Crisis Intervention	94
Policy #103	Behavior Interventions	95
Policy #104	Use of Restraint	96
Addendum: Restraints for Non-violent Intervention Gen. Training	97
Policy #105	General Crisis Plan	97
Emergency On-Call Process	100

Section 6:	Safety, Fire, and Sanitation		
Policy #101	Fire and Sanitation ...........................................................................	101	
Policy #102	Nutrition ..........................................................................................	102	
Policy #103	Preventive Maintenance ....................................................................	103	
Policy #104	Maintenance of Building and Equipment .............................................	103	
Policy #105	Vehicle Regulations ..........................................................................	104	

Policy #106	Universal Precautions ........................................................................	109	
Policy #107	First Aid ...........................................................................................	122	
Section 7: Rights and Confidentiality	
Policy #101	Respect ............................................................................................	123	
Policy #102	Confidentiality/HIPPA ........................................................................	123	
Policy #103	Protection of Rights ...........................................................................	124	
Policy #104	Communication Rights .......................................................................	134	
Policy #105	Human Rights Committee ..................................................................	135	
Policy #106	Complaint/Conflict Resolution .............................................................	137	
Policy #107	Sexuality ..........................................................................................	139	
Policy #108	Natural Supports ...............................................................................	140	
Policy #109	Volunteers ........................................................................................	141	
Policy #110	Title VI ..............................................................................................	142	
Policy #111	Limited English Proficiency .................................................................	144	
Policy #112	Conservative Power of Attorney Supportive Decision ............................	145	
Policy #113	Position Statement of Stakeholder Involvement ...................................	146	
Policy #114	Best Practice for CQL Indicators, Med Consent, Advisory ......................	148	

Section 8: Emergency Management
Policy #101	Emergency Precautions ......................................................................	150	
Policy #102	Medical Emergencies ..........................................................................	150	
Policy #103	Accident/Injury Investigations .............................................................	151	
Policy #104	Fire Evacuation Drills ..........................................................................	152	
Policy #105	Severe Weather Procedures ................................................................	153	
Policy #106	Description of Site Disaster Plans ........................................................	153	
	Disaster and Fire Evacuation Procedures ................................,............	155	
Policy #107	Disaster Plan .....................................................................................	156	
Policy #108	Research Information .........................................................................	160	
Policy #109	Internal Quality Assurance Program ....................................................	160	

III.	Person Centered Support Plan – Implementation Support Plan ECF Policies
Purpose and	Process ...............................................................................................	164	
Domain 1	Access and Orientation for Services ....................................................	165	
Domain 2	Person Centered Support Plan Implementation and Support Delivery ....	167	
Domain 3	Choice and Decision Making ...............................................................	170	
Domain 4	Opportunities for Integrated Work ......................................................	172	
Domain 5	Relationships and Community Membership ..........................................	173	
Domain 6	Rights, Respect, Dignity .....................................................................	175	
Domain 7	Health ..............................................................................................	177	
Domain 8	Safety and Security ...........................................................................	179	
Domain 9	Direct Support Staff ..........................................................................	182	

IV.	Technology Plan and Policies
Commitment to Technology	184
Positive Supports and Person Centered Principles	184
Assessment of Needs	185
HCBS Rules and Human Rights	185
Persons Supported Using Technology to Observe Activities in Their Home	185
Use of Technology for Employment Services Support	185
Outcomes and Goals	186
Self-Administration – Medication using Technology	186
Use of Automated Medication DPCSPensers	186
Technology Team	186
Technology Vendors – Selection and Expectations	187
Remote Support Plan	187
Back-Up Plan and On-Call Procedures	188
Check and Maintenance of Technology	188
Follow-Up and Documentation	188
Education	188
Information Technology Policies	189
V.	MAPS Policies and Procedures
MAPS Project Management: Medicaid Alternative Pathways to Independence	195
Who is eligible for MAPS?	195
What will the program provide?	195

BUFFALO RIVER SERVICES, INC. PROFESSIONAL SUPPORT SERVICES POLICIES and GENERAL POLICIES FOR ALL PROGRAMS
ADMINISTRATION
Policy:
Buffalo River Services, Inc. (BRS, Inc.) will maintain a structure and organization consistent with Tennessee’s Professional Support Services rules and regulations. These policies will apply to all BRS, Inc. programs.

Procedures:
1)	BRS, Inc. shall organize, manage, and administer its services to attain and maintain the highest practicable functional capacity for each consumer regarding nursing and therapy needs as indicated by the plan of care.

2)	BRS, Inc. shall develop and maintain administrative control of any site code.
3)	The organizational structure, professional support services provided, administrative control, and lines of authority for the delegation of responsibility down to the consumer care level shall be clearly set forth in writing and shall not be delegated to another agency.

4)	The Board of Directors shall: assume full legal authority and responsibility for the management and provision of all professional support services; fiscal operations; quality assessment and performance improvement programs. The Board of Directors shall appoint a qualified administrator (Executive Director) who is responsible for designating people to carry out these functions.
5)	The administrator shall organize and direct the organization’s ongoing functions, the professional personnel and the staff; employ qualified personnel and ensure adequate staff education and evaluation for all personnel involved in direct care; ensure the accuracy of public information materials and activities; and implement an effective budgeting and accounting system. The Nursing Services Program Director (Registered Nurse) shall assume temporary responsibility for the provision of professional support services during the administrator’s short-term absences.

6)	BRS, Inc. shall have a duly qualified administrator accessible during normal operating hours. Any change of administrators shall be reported to the Department of Health within fifteen (15) days.

7)	BRS, Inc. shall maintain an office with a working telephone that is staffed or takes voice messages during normal business hours.
1)	
8)	When licensure is applicable for a particular position of employment, a copy of the current license or the number and renewal number of the employee’s current license must be maintained in the employee’s personnel file. Each personnel file shall contain accurate information as to the education, training, experience and personnel background of the employee. Proof of adequate medical screening to exclude communicable disease shall be maintained in the file of each employee.

9)	Personnel practices shall be supported by written personnel policies. Personnel records shall include at a minimum: job descriptions, verification of references and credentials, and performance evaluations. Personnel records must be kept current. Agencies employing only one (1) staff member must maintain a personnel record with verification of current credentials.
10)	An ongoing educational program shall be planned and conducted for the development and improvement of skills of all the agency’s personnel engaged in delivery of professional support services. Each employee shall receive appropriate orientation to the agency, its policies, the employee’s position, and the employee’s duties. Records shall be maintained which indicate the subject of and attendance at such staff development programs.

11)	Supervision of unlicensed personnel must occur at a minimum of every thirty (30) days and must include direct observation of the provision of care, record review and individual conferences.

12)	Whenever the rules require that a licensee develop a written policy, plan, procedure, technique or system concerning a subject, BRS, Inc. shall develop the required policy, maintain it and adhere to its provisions.

13)	Policies and procedures shall be consistent with professionally recognized standards of practice.

14)	BRS, Inc. shall provide testing of consumers and staff for human immunodeficiency virus (HIV) and any other identified causative agent of acquired immune deficiency syndrome only when there exists a reasonable indication that a person may have contracted the virus and only for the purpose of treatment and prevention of further spreading. OSHA guidelines shall be followed.

15)	BRS, Inc. shall not retaliate against or, in any manner, discriminate against any person because of a complaint made in good faith and without malice to the Board, the Department, the Department of Human Services, Adult Protective Services, the state agency financially responsible for services to consumers, or the Comptroller of the State Treasury. BRS, Inc. shall neither retaliate nor discriminate because of information lawfully provided to these authorities, because of a person’s cooperation with them or because a person is subpoenaed to testify at a hearing involving one of these authorities.
1)	
ADMISSIONS, DISCHARGES, AND TRANSFERS.
Policy:

BRS, Inc. will provide Professional Support Services to those individuals supported by the agency following Physician orders and in accord with professionally recognized standards of practice.
Procedures:
1)	Consumers shall be accepted to receive professional support services on the basis of a reasonable expectation that the consumer’s nursing and therapy needs can be met adequately by the agency.
2)	Professional support services shall be provided as prescribed by the attending physician. The plan for providing professional support services and the expected outcomes shall be incorporated into the consumer’s plan of care or Person Centered Support Plan.
3)	BRS, Inc. staff shall determine if the consumer’s needs can be met by the agency’s services
and capabilities.
4)	The name of	the consumer’s attending physician shall be recorded in the consumer’s medical record.
5)	BRS, Inc. staff shall obtain the consumer’s or his/her designee’s written consent for
professional support services.
6)	The signed consent form shall be included with the consumer’s individual clinical record.
7)	A diagnosis must be entered in the admission records of the agency for every person admitted for care or treatment.
8)	No medication or treatment shall be provided to any consumer of the BRS, Inc. except on the order of a physician lawfully authorized to give an order.
9)	A medical record shall be developed and maintained for each consumer admitted.
10)	BRS, Inc. discharge planning process, including discharge policies and procedures, must be in writing and follow the guidelines established in the written agreement between BRS, Inc. and the  Department of Disability and Aging (DDA). If BRS, Inc. determines that they are no longer willing or able to provide services, they must comply with the following:
a)	Prior to discontinuation of authorized services, BRS, Inc. shall obtain approval from DDA;
b)	The agency shall notify the consumer, their conservator or guardian, the support coordinator, and DDA no less than sixty (60) days prior to the planned discharge;
c)	If the consumer or his/her representative request an appeal in accordance with
T.C.A. #33-2-601, et seq., the discharge will not occur prior to the final agency decision and resolution of the administrative appeal unless ordered by a court and approved by the state;
d)	BRS, Inc. shall continue to provide services until the consumer is provided with other services that are of acceptable and appropriate quality in order to maintain continuity of care; and
e)	If the consumer or his/her representative request to be discharged from BRS, Inc., the agency will follow the steps as outlined above and provide transfer documentation to
a)	
the new provider, if requested, in order to maintain continuity of care and facilitate transfer.

11)	BRS, Inc. shall ensure that no person on the grounds of race, color, national origin or handicap, will be excluded from participation in, be denied benefits of, or otherwise subjected to discrimination in the provision of any care or service of the agency. BRS, Inc. shall protect the civil right of residents under the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973.

BASIC AGENCY FUNCTIONS
Policy:
BRS, Inc. will provide integrated Professional Support Services to assure personal plans of treatment for each individual served, documentation, record keeping, professionally recognized standards of practice.

Procedure:
1)	All personnel providing professional support services shall assure that their efforts effectively complement other services provided to the consumer are functionally integrated into the Person Centered Support Plan. A written summary report for each consumer shall be sent to the attending physician at least annually.
2)	Plan of Care
a.	The written plan of care, developed in consultation with the agency staff, shall cover all pertinent diagnosis, including mental status, types of service and equipment required, frequency of services, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or
referral, and any other appropriate items. If a physician refers a consumer under a plan of care which cannot be completed until after an evaluation visit, the physician shall be consulted to approve additions or modifications to the original plan. Orders for professional support services shall include the specific treatment or modalities to be used and their amount, frequency and duration. The therapist and other agency personnel shall participate in developing the plan of care.
b.	The plan(s) of care for acute or episodic illness shall be reviewed by the attending physician and agency personnel involved in the consumer’s care as often as the severity of the consumer’s condition requires, but at least annually. Evidence of review by the physician must include the physician’s signature and date of the review on the plan of care. A facsimile of the physician’s signature is acceptable. Professional staff shall promptly alert the physician to any changes that suggest a need to alter the plan of care.

3)	Drugs and treatments shall be administered by appropriately licensed agency personnel, acting within the scope of their licenses. Orders for drugs and treatments shall be signed and dated by the physician.
1)	
4)	Skilled Nursing Services
a.	When skilled nursing is provided, the services shall be provided by or under the supervision of a registered nurse who has no current disciplinary action against his/her license, in accordance with the plan of care. This person shall be available at all times during operating hours and participate in all activities relevant to the professional support services provided, including the development of qualifications and assignment of personnel.
b.	The registered nurse’s duties shall include but are not limited to the following: make the initial evaluation visit, except in those circumstances where the physician has ordered therapy services, as the only skilled service; regularly evaluate the consumer’s nursing needs; initiate the plan of care and necessary revisions; provide those services requiring substantial specialized nursing skill; initiate appropriate preventive and rehabilitative nursing procedures; prepare clinical and progress notes; coordinate services; inform the physician and other personnel of changes in the consumer’s condition and needs; counsel the consumer and family in meeting nursing and related needs; participate in
in-service programs; supervise and teach other nursing personnel. The registered nurse or appropriate agency staff shall initially and periodically evaluate drug interactions, duplicative drug therapy and noncompliance to drug therapy.
c.	The licensed practical nurse shall provide services in accordance with agency policies, which include but are not limited to the following: prepare clinical progress notes; assist the physician and/or registered nurse in performing specialized procedures; prepare equipment and materials for treatment; observe aseptic technique as required; and assist the consumer in learning appropriate self-care techniques.

5)	Therapy Services
a.	All therapy services offered by the agency directly or under arrangement shall be planned, delegated, supervised or provided by a qualified therapist in accordance with the plan of care. A qualified therapist assistant may provide therapy services under the supervision of a qualified therapist in accordance with the plan of care. The therapist shall assist the physician in evaluating the level of function, helping develop the plan of care (revising as necessary), preparing clinical and progress notes, advising and consulting with the family and other agency personnel, and participating in in-service programs.
b.	Speech therapy services shall be provided only by a licensed speech language pathologist in good standing or speech language pathologist in the Clinical Fellowship Year under the supervision of a licensed speech language pathologist.
6)	Performance Improvement
a.	BRS, Inc. shall have a committee or mechanism in place to review, at least annually, past and present professional support services, including contract services, in accordance with a written plan, to determine their appropriateness and effectiveness and to ascertain that professional policies are followed in providing these services. The Guidance Team will serve as this committee.
b.	The objectives of the review committee shall be:
a.	
1.	To assist BRS, Inc. in using its personnel and facilities to meet individual and community needs;
2.	To identify and correct deficiencies which undermine quality of care and lead to waste of agency and personnel resources;
3.	To help BRS, Inc. make critical judgments regarding the quality and quantity of its services through self-examination;
4.	To provide opportunities to evaluate the effectiveness of agency policies and when necessary make recommendations to the administration as to changes needed to assure high standards of consumer care;
5.	To augment in-service staff education, when applicable;
6.	To provide data needed to satisfy state licensure and certification requirements;
7.	To establish criteria to measure the effectiveness and efficiency of the professional support services provided to consumers; and
8.	To develop a record review system for the agency to evaluate the necessity or appropriateness of the professional support services provided and their effectiveness and efficiency. (Monthly on-site RN supervisory report.)

7)	Infection Control
a.	There shall be an active performance improvement program for developing guidelines, policies, procedures and techniques for the prevention, control and investigation of infections and communicable diseases.
b.	BRS, Inc. shall coordinate the education and orientation of all appropriate personnel and/or family members in the practice of aseptic techniques such as hand washing practices, proper hygiene, use of personal protective equipment, dressing care techniques, disinfecting and sterilizing techniques, and the handling and storage of consumer care equipment and supplies.
c.	Continuing education shall be provided for all agency consumer care providers on the cause, effect, transmission, prevention and elimination of infections, as evidenced by the ability to verbalize/or demonstrate an understanding of basic techniques.
d.	BRS, Inc. shall follow OSHA guidelines for testing a consumer’s blood for the presence of the hepatitis B virus and the HIV (AIDS) virus in the event that an employee of the agency or other health care provider rendering services at the agency is exposed to a consumer’s blood or other bodily fluids. The testing shall be performed at no charge to the consumer, and the test results shall be confidential.
e.	BRS, Inc. and its employees shall utilize standard precautions (per CDC) for preventing transmission of infections, HIV and communicable diseases.
f.	Precautions shall be taken to prevent the contamination of sterile and clean supplies by soiled supplies. Sterile supplies shall be packaged and stored in a manner that protects the sterility of the contents.

8)	Medical Records
a.	A medical record containing past and current findings in accordance with accepted professional standards shall be maintained for every consumer receiving professional support services. In addition to the plan of care, the record shall contain; appropriate identifying information; name of physician; all medications and treatments; signed and dated clinical notes. Clinical notes shall be written the day on which service is rendered
a.	
and incorporated no less often than weekly; copies of summary reports shall be sent to the physician; and a discharge summary shall be dated and signed within 7 days of discharge.
b.	All medical records, either in written, electronic, graphic or other acceptable form, shall be retained in their original or legally reproduced form for a minimum period of at least ten (10) years after which such records may be destroyed. Record destruction shall be accomplished by burning, shredding, or other effective method in keeping with the confidential nature of the contents. The destruction of records shall be made in the ordinary course of business, shall be documented in accordance with the agency’s policies and procedures, and no record may be destroyed on an individual basis.
c.	If BRS, Inc. discontinues operations, records shall be maintained as mandated by the PSS rules and the Tennessee Medical Records Act (T.C.A. 68-11-308). If a consumer is transferred to another health care facility or agency, a copy of the record or an abstract shall accompany the consumer when BRS, Inc. is directly involved in the transfer.
d.	Medical records information shall be safeguarded against loss or unauthorized use. Only authorized agency staff, the consumer and his/her conservator, and authorized survey team members will have access. The consumer’s written consent shall be required for release of information when the release is not otherwise authorized by law.
e.	The requirements for signature or countersignature by a physician or other person responsible for signing, countersigning or authenticating an entry may be satisfied by the electronic entry by such person of a unique code assigned exclusively to him or her, or by entry of other unique electronic or mechanical symbols, provided that such person has adopted same as his or her signature in accordance with established protocol or rules.

INFECTIOUS AND HAZARDOUS WASTE
Policy:
BRS, Inc. will comply with all applicable state and federal regulations and professionally recognized standards of practice related to the handling of infectious and hazardous waste.

Procedure:
1)	The following waste shall be considered to be infectious waste:
a.	Waste human blood products such as serum, plasma, and other blood components;
b.	All discarded sharps (including but not limited to, hypodermic needles, syringes, Pasteur pipettes, broke glass, scalpel blades) used in consumer care; and
c.	Other waste determined to be infectious by the agency in its written policy.
2)	Waste shall be packaged in a manner that will protect waste handlers and the public from possible injury and disease that may result from exposure to the waste. Such packaging must provide for containment of the waste from the point of generation up to the point of proper treatment or dPCSPosal. Packaging shall be selected and utilized for the type of waste the package will contain, how the waste will be treated and dPCSPosed, and how it will be handled and transported prior to treatment and dPCSPosal.
a.	Contaminated sharps shall be directly placed in leak proof, rigid and puncture-resistant containers which shall then be tightly sealed.
a.	
b.	Infectious and hazardous waste shall be secured in fastened plastic bags before placement in a garbage can with other household waste.
c.	Reusable containers for infectious waste shall be thoroughly sanitized each time they are emptied, unless the surfaces of the containers have been completely protected from contamination by disposed liners or other devices removed with the waste.
3)	After packaging, waste shall be handled, transported and stored by methods ensuring containment and preserving of the integrity of the packaging, including the use of secondary containment where necessary.
4)	Waste shall be removed in a manner which preserves the integrity of the packaging, inhibits rapid microbial growth and putrefaction, and minimizes the potential of exposure or access by unknowing persons. Waste shall be stored in a manner and location which affords protection from animals, precipitation, wind and direct sunlight, does not present a safety hazard, does not provide a breeding place or food source for insects or rodents and does not create a nuisance.
5)	In the event of spills, ruptured packaging, or other incidents where there is loss of containment of waste, BRS, Inc. shall ensure that proper actions are immediately taken to:
a.	Isolate the area;
b.	Repackage all spilled waste and contaminated debris in accordance with the requirements of this rule; and
c.	Sanitize all contaminated equipment and surface appropriately.

RECORDS AND REPORTS
POLICY:
BRS, Inc. will maintain required records and submit all required reports to comply with the Professional Support Services rules and to provide adequate and appropriate information in support of the individual served.

PROCEDURE:
1)	BRS, Inc. will retain legible copies of the following records and reports for thirty-six (36) months following their issuance. They shall be maintained in a single file and shall be made available for inspection during normal business hours to any person who requests to view them:
a.	Department licensure and fire safety inspections and surveys;
b.	Centers for Medicare and Medicaid Services (CMS) surveys and inspections, if any;
c.	Orders of the Commissioner or Board, if any; and
d.	Comptroller of the Treasury’s audit report and finding, if any.
2)	BRS, Inc. will report all incidents of abuse, neglect, and misappropriation to the Department of Health in accordance with TCA 68-11-211.
3)	BRS, Inc. will report the following incidents to the Department of Health in accordance with TCA 68-11-211.
a.	Strike by the staff at the agency;
b.	External disaster impacting the agency;
c.	Disruption of any service vital to the continued safe operation of the agency or to the health and safety of its consumers and personnel; and
a.	
d.	Fires at the agency which disrupt the provision of consumer care services or cause harm to consumers or staff, or which are reported by the agency to any entity, including but not limited to a fire department charged with preventing fires.

CONSUMER RIGHTS
POLICY:
BRS, Inc. will assure each consumer’s rights are protected.
PROCEDURE:
1)	Each consumer has at least the following rights:
a.	To privacy in treatment and personal care;
b.	To have appropriate assessment and management of pain;
c.	To be involved in the decision making and all aspects of their care;
d.	To be free from mental and physical abuse. Should this right be violated,
BRS, Inc. must notify the Department within five (5) business days and the Tennessee Department of Human Services, and Adult Protective Services as required by TCA 71-6- 101 et seq.;
e.	To refuse treatment. The consumer must be informed of the consequences of that decision, and the refusal and its reasons must be reported to the physician and documented in the medical record;
f.	To refuse experimental treatment and drugs. The consumer’s written consent for participation in research must be obtained and retained in his or her medical record; and
g.	To have his or her records kept confidential and private. Written consent by the consumer must be obtained prior to release of information except to persons authorized by law. If the consumer is mentally incompetent, written consent is required from the consumer’s legal representative. BRS, Inc. must have policies to govern access and duplication of the consumer’s record.
2)	Each consumer has a right to self-determination, which encompasses the right to make choices regarding life-sustaining treatment, including resuscitative services. This right of self-determination may be effectuated by an advance directive.

HEALTH CARE DECISION MAKING
POLICY:
BRS, Inc. shall maintain and establish policies and procedures governing the designation of a health care decision-maker for making health care decisions for a service recipient who is incompetent or who lacks capacity, including but not limited to allowing the withholding of CPR measures from an individual.

PROCEDURE:
1)	An adult may give an individual instruction. The instruction may be oral or written. The instruction may be limited to take effect only if a specified condition arises. The advance directive:
1)	
a.	May authorize an agent to make any health care decision the service recipient could have made while having the capacity, or
b.	May limit the power of the agent, and
c.	May include individual instructions.
2)	The effort of an advanced directive that makes no limitation on the agent’s authority shall be to authorize the agent to make any health care decision the service recipient could have made while having the capacity.
3)	The advance directive shall be written, signed by the service recipient, and shall either be notarized or witnessed by two (2) witnesses. Both witnesses shall be competent adults, and neither of them may be the agent. At least one (1) of the witnesses shall be a person who is not related to the service recipient by blood, marriage, or adoption and would not be entitled to any portion of the estate of the service recipient upon the death of the service recipient. The advance directive shall contain a clause that attests that the witnesses comply with the requirements of this paragraph.
4)	Unless otherwise specified in an advance directive, the authority of an agent becomes effective only upon a determination that the service recipient lacks capacity, and ceases to be effective upon a determination that the service recipient has recovered capacity.
5)	A facility shall use an advance directive form that meets the requirements of the Tennessee Health Care Decisions Act or has been developed and issued by the Board for Licensing Health Care Facilities.
6)	A determination that a service recipient lacks or has recovered capacity, or that another condition exists that affects an individual instruction or the authority of an agent shall be made by the designated physician, who is authorized to consult with such other persons as his/her may deem appropriate.
7)	An agent shall make a health care decision in accordance with the service recipient’s individual instructions, if any, and other wishes to the extent known to the agent. Otherwise, the agent shall make the decision in accordance with the service recipient’s best interest. In determining the service recipient’s best interest, the agent shall consider the service recipient’s personal values to the extent known.
8)	An advance directive may include the individual’s nomination of a court-appointed guardian/conservator.
9)	A health care facility shall honor an advance directive that is executed outside of this state by a nonresident of this state at the time of execution if that advance directive is in compliance with the laws of Tennessee.
10)	No health care provider or institution shall require the execution or revocation of an advance directive as a condition for receiving services.
11)		Any living will, durable power of attorney for health care, or other instrument signed by the individual, complying with the terms of T.C.A. Title 32, Chapter 11, and a durable power of attorney for health care complying with the terms of T.C.A. Title 34, Chapter 6, Part 2, shall be given effect and interpreted in accord with those respective acts. Any advance directive that does not evidence an intent to be given effect under those acts but complies with these policies may be treated as an advance directive under these policies.
12)	A service recipient having capacity may revoke the designation of an agent only by a signed writing or by personally informing the supervising health care provider.
13)		A service recipient having capacity may revoke all or part of an advance directive, other than the designation of an agent, at any time and in a manner that communicates intent to revoke.
1)	
14)		A decree of annulment, divorce, dissolution of marriage, or legal separation revokes a previous designation of a spouse as an agent unless otherwise specified in the decree or in an advanced directive.
15)		An advance directive that conflicts with an earlier advance directive revokes the earlier directive to the extent of the conflict.
16)	SURROGATES:
a.	An adult may designate any individual to act as surrogate by personally informing the supervising health care provider. The designation may be oral or written;
b.	A surrogate may make a health care decision for a service recipient who is an adult if and only if:
1.	The service recipient has been determined by the designated physician to lack capacity, and
2.	No agent or guardian/conservator has been appointed, or
3.	The agent or guardian/conservator is not reasonably available.
c.	In the case of a service recipient who lacks capacity, the service recipient’s surrogate shall
be identified by the supervising health care provider.
d.	The service recipient’s surrogate shall be an adult who has exhibited special care and concern for the service recipient, who is familiar with the service recipient’s personal values, who is reasonably available, and who is willing to serve.
e.	Consideration may be, but need not be, given in order of descending preference for service as a surrogate to:
1.	The service recipient’s spouse, unless legally separated;
2.	The service recipient’s adult child;
3.	The service recipient’s parent;
4.	The service recipient’s adult sibling;
5.	Any other adult relative of the service recipient; or
6.	Any other adult who satisfies the requirements of 1200-08-34.13(16)(d).
f.	No person who is the subject of a protective order or other court order that directs that person to avoid contact with the service recipient shall be eligible to serve as the service recipient’s surrogate.
g.	The following criteria shall be considered in the determination of the person best qualified to serve as the surrogate:
1.	Whether the proposed surrogate reasonably appears to be better able to make decisions either in accordance with the known wishes of the service recipient or in accordance with the service recipient’s best interests;
2.	The proposed surrogate’s regular contact with the service recipient prior to and during
the incapacitating illness;
3.	The proposed surrogate’s demonstrated care and concern;
4.	The proposed surrogate’s availability to visit the service recipient during his or her
illness; and
5.	The proposed surrogate’s availability to engage in face-to-face contact with health care providers for the purpose of fully participating in the decision-making process.
h.	If the service recipient lacks capacity and none of the individuals eligible to act as a surrogate under 1200-08-34-.13 (16)(C) thru 1200-08-34.13(16)(g) is reasonably available, the designated physician may make health care decisions for the service recipient after the designated physician either:
a.	
1.	Consults with and obtains the recommendations of a facility’s ethics mechanism or a
standing committee in the facility that evaluated health care issues; or
2.	Obtains concurrence from a second physician who is not directly involved in the service recipient’s health care, does not serve in a capacity of decision-making, influence, or responsibility over the designated physician, and is not under the designated physician’s decision-making, influence, or responsibility.
i.	In the event of a challenge, there shall be a rebuttable presumption that the selection of the surrogate was valid. Any person who challenges the selection shall have the burden of proving the invalidity of that selection.
j.	A surrogate shall make a health care decision in accordance with the service recipient’s individual instructions, if any, and other wishes to the extent known to the surrogate. Otherwise, the surrogate shall make the decision in accordance with the surrogate’s determination of the service recipient’s best interest. In determining the service recipient’s best interest, the surrogate shall consider the service recipient’s personal values to the extent known to the surrogate.
k.	A surrogate who has not been designated by the service recipient may make all health care decisions for the service recipient that the service recipient could make on the service recipient’s own behalf, except that artificial nutrition and hydration may be withheld or withdrawn from a service recipient upon a decision of the surrogate only when the designated physician, a second independent physician, certify in the service recipient’s current clinical records that the provision or continuation of artificial nutrition or hydration is merely prolonging the act of dying and the service recipient is highly unlikely to regain capacity to make medical decisions.
l.	Except as provided in 1200-08-34-.13(16)(m):
1.	Neither the treating health care provider nor an employee of the treating health care provider, nor an operator of a health care institution, nor an employee of an operator of a health care institution maybe designated as a surrogate; and
2.	A health care provider or employee of a health care provider may not act as a surrogate
if the health care provider becomes the service recipient’s treating health care provider.
m.	An employee of the treating health care provider or an employee of an operator of a health care institution may be designated as a surrogate if:
1.	The employee so designated is a relative of the service recipient by blood, marriage, or adoption; and
2.	The other requirements of this section are satisfied.
n.	A health care provider may require an individual claiming the right to act as a surrogate for a service recipient to provide written documentation stating facts and circumstances reasonably sufficient to establish the claimed authority.
17.	GUARDIANS
a.	A guardian shall comply with the service recipient’s individual instructions and may not revoke the service recipient’s advance directive absent a court order to the contrary.
b.	Absent a court order to the contrary, a health care decision of an agent takes precedence over that of a guardian.
c.	A health care provider may require an individual claiming the right to act as guardian for a service recipient to provide written documentation stating facts and circumstances reasonably sufficient to establish the claimed authority.
18.	A designated physician who makes or is informed of a determination that a service
17.	
recipient lacks or has recovered capacity, or that another condition exists which affects an individual instruction or the authority of an agent, guardian, or surrogate, shall promptly record the determination in the service recipient’s current clinical record and communicate the determination to the service recipient, if possible, and to any person then authorized to make health care decisions for the service recipient.
19.	Except as provided in 1200-08-34.13(20) thru 1200-08-34.13(22), a health care provider or institution providing care to a service recipient shall:
a.	comply with an individual instruction of the service recipient and with a reasonable interpretation of that instruction made by a person then authorized to make health care decisions for the service recipient; and
b.	comply with a health care decision for the service recipient made by a person then authorized to make health care decisions for the service recipient to the same extent as if the decision had been made by the service recipient while having capacity.
20.	A health care provider may decline to comply with an individual instruction or health care decision for reasons of conscience.
21.	A health care institution may decline to comply with an individual instruction or health care decision if the instruction or decision is:
a.	contrary to a policy of the institution which is based on reasons of conscience, and
b.	the policy was timely communicated to the service recipient or to a person then authorized to make health care decisions for the service recipient.
22.	A health care provider may decline to comply with an individual instruction or health care decision that requires medically inappropriate health care or health care contrary to generally accepted health care standards applicable to the health care provider or institution.
23.	A health care provider or institution that declines to comply with an individual instruction or health care decision pursuant to 1200-08-34-.13(20) thru 120008-34-.13(22) shall:
a.	promptly so inform the service recipient, if possible, and any other person then authorized to make health care decisions for the service recipient;
b.	provide continuing care to the service recipient until a transfer can be affected or until the determination has been made that transfer cannot be affected,
c.	unless the service recipient or person then authorized to make health decisions for the service recipient refuses assistance, immediately make all reasonable efforts to assist in the transfer of the service recipient to another health care provider or institution that is willing to comply with the instruction or decision; and
d.	if a transfer cannot be affected, the health care provider or institution shall not be compelled to comply.
24.	Unless otherwise specified in an advance directive, a person then authorized to make health care decisions for a service recipient has the same rights as the service recipient to request, receive, examine, copy, and consent to the disclosure of medical or any other health care information.
25.		A health care provider or institution acting in good faith and in accordance with generally accepted health care standards applicable to the health care provider or institution is not subject to civil or criminal liability or to discipline for unprofessional conduct for:
a.	complying with a health care decision of a person apparently having authority to make a health care decision for a service recipient, including a decision to withhold or withdraw health care;
a.	
b.	declining to comply with a health care decision of a person based on a belief that the person then lacked authority; or
c.	Complying with an advance directive and assuming that the directive was valid when made and had not been revoked or terminated.
26.		An individual acting as an agent or surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for health care decisions made in good faith.
27.		A person identifying a surrogate is not subject to civil or criminal liability or to discipline for unprofessional conduct for such identification made in good faith.
28.		A copy of written advance directive, revocation of an advance directive, or designation or disqualification of a surrogate has the same effect as the original.
29.	The withholding or withdrawal of medical care from a service recipient in accordance with the provisions of the Tennessee Health Care Decisions Act shall not, for any purpose, constitute a suicide, euthanasia, homicide, mercy killing, or assisted suicide.
30.	Universal Do Not Resuscitate Order (DNR).
a.	The Physicians Order for Scope of Treatment (POST) form, a form meeting the provisions of the Health Care Decisions Act and approved by the Board of Licensing Health Care Facilities, may be used as the Universal Do Not Resuscitate Order by all facilities. A universal Do Not Resuscitate order (DNR) may be issued by a physician for his/her patient with whom he/she has a physician/patient relationship, but only:
i.	With the consent of the patient; or
ii.	If the patient is incapable of making an informed decision regarding consent for such an order, upon the request of and with the consent of the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act; or
iii.	If the patient is incapable of making an informed decision regarding consent for such an order and the agent, surrogate, or other person authorized to consent on the patient’s behalf under the Tennessee Health Care Decisions Act is not reasonably available, the physician determines that the provision of cardiopulmonary resuscitation would be contrary to accepted medical standards.
b.		If the service recipient is an adult who is capable of making an informed decision, the service recipient’s expression of the desire to be resuscitated in the event of cardiac or respiratory arrest shall revoke a universal Do Not Resuscitate order.
c.	If the service recipient is incapable of making an informed decision, the expression of the desire that the service recipient be resuscitated by the person authorized to consent on the service recipient’s behalf shall revoke a universal Do Not Resuscitate order.
d.	Universal Do Not Resuscitate order shall remain valid and in effect until revoked. Qualified emergency medical services personnel, and licensed health care practitioners in any facility, program or organization operated or licensed by the board for licensing health care facilities or by the department of mental health and developmental disabilities or operated, licensed, or owned by another state agency are authorized to follow universal Do Not Resuscitate orders.
e.	Nothing in these rules shall authorize the withholding of other medical interventions, such as intravenous fluids, oxygen, or other therapies deemed necessary to provide comfort care or to alleviate pain.
f.	If a person with a universal Do Not Resuscitate order is transferred from one health care
a.	
facility to another health care facility, the health care facility initiating the transfer shall communicate the existence of the Universal Do Not Resuscitate order to the receiving facility prior to the transfer. The transferring facility shall assure that a copy of the Universal Do Not Resuscitate order accompanies the service recipient in transport to the receiving health care facility. Upon admission, the receiving facility shall make the Universal Do Not Resuscitate order a part of the service recipient’s record. The POST form promulgated by the Board for Licensing Health Care Facilities shall serve as the Universal Do Not Resuscitate Order form when transferring an individual from one health care facility to another health care facility.
g.		This section shall not prevent, prohibit, or limit a physician from issuing a written order other than a Universal Do Not Resuscitate order not to resuscitate a service recipient in the event of cardiac or respiratory arrest in accordance with accepted medical practices.
h.	Valid Do Not Resuscitate orders or emergency medical services Do Not Resuscitate orders issued before July 1, 2004, pursuant to the then-current law, shall remain valid and shall be given effect as provided.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This notice will tell you how we may use and disclose protected health information about you. Protected health information means any health information about you that identifies you or for which there is a reasonable basis to believe the information can be used to identify you. In the header above, that information is referred to as “medical information.” In this notice, we call all of that protected health information, “medical information.” This notice also will tell you about your rights and our duties with respect to health information about you. In addition, it will tell you how to complain to us if you believe we have violated your privacy rights.

Who Is Bound By This Notice?
This Notice of Privacy Practices describes our practices as of April 14, 2003.
This notice applies to the following delivery sites: All Buffalo River Services, Inc. locations. We all will follow what is stated in this Notice.

How We May Use and Disclose Health Information About You.
We will share health information about you with each other as necessary to carry out treatment, payment, or our health care operations. We use and disclose health information about you for a number of different purposes. Each of those purposes is described below.
For Treatment.
We may use health information about you to provide, coordinate or manage the services, supports, and health care you receive from us and other providers. We may disclose health information about you to doctors, nurses, qualified mental retardation professionals, psychologists, social workers, direct support staff and other agency staff, volunteers and other persons who are involved in supporting you or providing care. We may consult with other health care providers concerning you and, as part of the consultation, share your health information with them. For example, staff may discuss your information to develop

and carry out your individual service plan. Staff may share information to coordinate needed services, such as medical tests, transportation to a doctor’s visit, physical therapy, etc. Staff may need to disclose health information to entities outside of our organization (for example, another provider or a state/local agency) to obtain new services for you.
For Payment.
We may use and disclose health information about you so we can be paid for the services we provide to you. This can include billing a third-party payor, such as Medicaid or other state agency (for example, the state’s Office of Mental Retardation), or your insurance company. For example, we may need to provide the state Medicaid program information about the services we provide to you so we will be reimbursed for those services. We also may need to provide the state Medicaid program with information to ensure you are eligible for the medical assistance program. We may also need to disclose health information to your circle of support and case manager.

For Health Care Operations.
We may use and disclose health information about you for our own operations. These are necessary for us to operate and to maintain quality health for our patients. For example, we may use health information about you to review the services we provide and the performance of our employees supporting you. We may disclose health information about you to train our staff and volunteers. We also may use the information to study ways to more efficiently manage our organization, for accreditation or licensing activities, or for our compliance program.

How We Will Contact You.
Unless you tell us otherwise in writing, we may contact you by either telephone or by mail at either your home or your workplace. At either location, we may leave messages for you on the answering machine or voice mail. If you want to request that we communicate to you in a certain way or at a certain location, you need to request that of us. Notify The current staff person, Vice President of Compliance, Buffalo River Services, Inc., P. O. Box 847, Waynesboro, TN 38485 in writing.
Appointment Reminders.
We may use and disclose health information about you to contact you to remind you of an appointment for treatment or services.

Treatment and Service Alternatives.
We may use and disclose health information about you to contact you about treatment and service alternatives that may be of interest to you.

Health Related Benefits and Services.
We may use and disclose health information about you to contact you about health-related benefits and services that may be of interest to you.

Marketing Communications.
We may use and disclose health information about you to communicate with you about a product or service to encourage you to purchase the product or service. This may be:

•	To describe a health-related product or service that is provided by us;
•	For your treatment;
•	For case management or care coordination for you;

•	To direct or recommend alternative treatments, therapies, health care providers, or settings of care.

We may communicate to you about products and services in a face-to-face communication by us to you. We also may communicate about products or services in the form of a promotional gift of nominal value.

All other use and disclosure of health information about you by us to make a communication about a product or service to encourage the purchase or use of a product or service will be done only with your written authorization.

Fundraising.
We may use and disclose health information about you to raise funds for Buffalo River Services, Inc. We may disclose health information to a business associate of Buffalo River Service, Inc. or a foundation related to Buffalo River Service, Inc. so that business associate or foundation may contact you to raise money for the benefit of Buffalo River Service, Inc. We will only release demographic information, such as your name and address, and the dates you received treatment or services from Buffalo River Service, Inc. If you do not want Buffalo River Service, Inc. Or its foundation, the William Thomas Helton Foundation, to contact you for fundraising, you must notify The current staff person, Vice President of Compliance, Buffalo River Services, Inc., P. O. Box 847, Waynesboro, TN 38485in writing.

Directory.
We may include your name, your location in our facility, your condition described in general terms, and your religious affiliation in our directory while you receive services. This information, except for your religious affiliation may be released to people who ask for you by name. Your religious affiliation may be given to members of the clergy, such as a minister, priest or rabbi, who ask for you by name. If you do not want included in our facility directory, or you want to restrict the information we include in the directory, you must notify The current staff person, Vice President of Compliance, Buffalo River Services, Inc., P. O. Box 847, Waynesboro, TN 38485 of your objection.

Disclosures to Family and Others.
We may disclose to a parent/guardian, personal representative, family member, other relative, a close personal friend, circle of support, case manager or any other person

identified by you, health information about you that is directly relevant to that person’s involvement with the services and supports you receive or payment for those services and supports. We also may use or disclose health information about you to notify, or assist in notifying, those persons of your location, general condition, or death. If there is a family member, other relative, or close personal friend that you do not want use to disclose health information about you to, please notify The current staff person, Vice President of Compliance, Buffalo River Services, Inc., P. O. Box 847, Waynesboro, TN 38485 or tell our staff member who is providing care to you.

Disaster Relief.
We may use or disclose health information about you to a public or private entity authorized by law or by its charter to assist in disaster relief efforts. This will be done to coordinate with those entities in notifying a parent/guardian, personal representative, family member, other relative, close personal friend, or other person identified by you of your location, general condition or death.
Required by Law.
We may use or disclose health information about you when we are required to do so by law.
Public Health Activities.
We may disclose health information about you for public health activities and purposes. This includes reporting health information to a public health authority that is authorized by law to collect or receive the information for purposes of preventing or controlling disease. Or, one that is authorized to receive reports of child abuse and neglect. It also includes reporting for purposes of activities related to the quality, safety or effectiveness of a United States Food and Drug administration regulated product or activity.

Victims of Abuse, Neglect or Domestic Violence.
We may disclose health information about you to a government authority authorized by law to receive reports of abuse, neglect, or domestic violence, if we believe you are a victim of abuse, neglect, or domestic violence. This will occur to the extent the disclosure is: (a) required by law; (b) agreed to by you or your personal representative; or, (c) authorized by law and we believe the disclosure is necessary to prevent serious harm to you or to other potential victims, or, if you are incapacitated and certain other conditions are met, a law enforcement or other public official represents that immediate enforcement activity depends on the disclosure.

Health Oversight Activities.
We may disclose health information about you to a health oversight agency for activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions. These and similar types of activities are necessary for appropriate oversight of the health care system, government benefit programs, and entities subject to various government regulations.
Judicial and Administrative Proceedings.
We may disclose health information about you in the course of any judicial or administrative proceeding in response to an order of the court or administrative tribunal.

We also may disclose health information about you in response to a subpoena, discovery request, or other legal process but only if efforts have been made to tell you about the request or to obtain an order protecting the information to be disclosed.
Disclosures for Law Enforcement Purposes.
We may disclose health information about you to a law enforcement official for law enforcement purposes:

a.	As required by law.
a.	In response to a court, grand jury or administrative order, warrant or subpoena.

b.	To identify or locate a suspect, fugitive, material witness or missing person.

c.	About an actual or suspected victim of a crime and that person agrees to the disclosure. If we are unable to obtain that person’s agreement, in limited circumstances, the information may still be disclosed.
d.	To alert law enforcement officials to a death if we suspect the death may have resulted from criminal conduct.
e.	About crimes that occur at our facility.

f.	To report a crime in emergency circumstances.
Coroners and Medical Examiners.
We may disclose health information about you to a coroner or medical examiner for purposes such as identifying a deceased person and determining cause of death.

Funeral Directors.
We may disclose health information about you to funeral directors as necessary for them to carry out their duties.

Organ, Eye or Tissue Donation.
To facilitate organ, eye or tissue donation and transplantation, we may disclose health information about you to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue.

Research.
Under certain circumstances, we may use or disclose health information about you for research. Before we disclose health information for research, the research will have been approved through an approval process that evaluates the needs of the research project with your needs for privacy of your health information. We may, however, disclose health information about you to a person who is preparing to conduct research to permit them to prepare for the project, but no health information will leave the premises during that person’s review of the information.
To Avert Serious Threat to Health or Safety.

We may use or disclose protected health information about you if we believe the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public. We also may release information about you if we believe the disclosure is necessary for law enforcement authorities to identify or apprehend an individual who admitted participation in a violent crime or who is an escapee from a correctional institution or from lawful custody.
Military.
If you are a member of the Armed Forces, we may use and disclose health information about you for activities deemed necessary by the appropriate military command authorities to assure the proper execution of the military mission. We may also release information about foreign military personnel to the appropriate foreign military authority for the same purposes.

National Security and Intelligence.
We may disclose health information about you to authorized federal officials for the conduct of intelligence, counter-intelligence, and other national security activities authorized by law.

Protective Services for the President.
We may disclose health information about you to authorized federal officials so they can provide protection to the President of the United States, certain other federal officials, or foreign heads of state.

Security Clearances.
We may use health information about you to make medical suitability determinations and may disclose the results to officials in the United States Department of State for purposes of a required security clearance or service abroad.

Inmates; Persons in Custody.
We may disclose health information about you to a correctional institution or law enforcement official having custody of you. The disclosure will be made if the disclosure is necessary: (a) to provide health care to you; (b) for the health and safety of others; or, (c) the safety, security and good order of the correctional institution.
Workers Compensation.
We may disclose health information about you to the extent necessary to comply with workers’ compensation and similar laws that provide benefits for work-related injuries or illness without regard to fault.
Other Uses and Disclosures.
Other uses and disclosures will be made only with your written authorization. You may revoke such an authorization at any time by notifying Phil Garner, Executive Director, Buffalo River Services, Inc., P. O. Box 847, Waynesboro, TN 38485 in writing of your desire to revoke it. However, if you revoke such an authorization, it will not have any

effect on actions taken by us in reliance on it.
Your Rights With Respect to Health Information About You.

You have the following rights with respect to health information that we maintain about you.
Right to Request Restrictions.
You have the right to request that we restrict the uses or disclosures of health information about you to carry out treatment, payment, or health care operations. You also have the right to request that we restrict the uses or disclosures we make to: (a) a family member, other relative, a close personal friend or any other person identified by you; or, (b) for to public or private entities for disaster relief efforts. For example, you could ask that we not disclose health information about you to your brother or sister.

To request a restriction, you may do so at any time. If you request a restriction, you should do so to Phil Garner, Executive Director, Buffalo River Services, Inc., P. O. Box 847, Waynesboro, TN 38485 and tell us: (a) what information you want to limit; (b) whether you want to limit use or disclosure or both; and, (c) to whom you want the limits to apply (for example, disclosures to your spouse).
We are not required to agree to any requested restriction. However, if we do agree, we will follow that restriction unless the information is needed to provide emergency treatment. Even if we agree to a restriction, either you or we can later terminate the restriction.

Right to Receive Confidential Communications.
You have the right to request that we communicate health information about you to you in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. We will not require you to tell us why you are asking for the confidential communication.

If you want to request confidential communication, you must do so in writing to Phil Garner, Executive Director, Buffalo River Services, Inc., P. O. Box 847, Waynesboro, TN 38485. Your request must state how or where you can be contacted.
We will accommodate your request. However, we may, if necessary, require information from you concerning how payment will be handled. We also may require an alternate address or other method to contact you.

Right to Inspect and Copy.
With a few very limited exceptions, such as psychotherapy notes, you have the right to inspect and obtain a copy of health information about you.
To inspect or copy health information about you, you must submit your request in writing to Phil Garner, Executive Director, Buffalo River Services, Inc., P. O. Box 847, Waynesboro, TN 38485. Your request should state specifically what health information you want to

inspect or copy. If you request a copy of the information, we may charge a fee for the costs of copying and, if you ask that it be mailed to you, the cost of mailing.

We will act on your request within thirty (30) calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request and provide access and copying.
We may deny your request to inspect and copy health information if the health information involved is:
a.	Psychotherapy notes;
b.	Information compiled in anticipation of, or use in, a civil, criminal or administrative action or proceeding;

If we deny your request, we will inform you of the basis for the denial, how you may have our denial reviewed, and how you may complain. If you request a review of our denial, it will be conducted by a licensed health care professional designed by us who was not directly involved in the denial. We will comply with the outcome of that review.
Right to Amend.
You have the right to ask us to amend health information about you. You have this right for so long as the health information is maintained by us.
To request an amendment, you must submit your request in writing to Phil Garner, Executive Director, Buffalo River Services, Inc., P. O. Box 847, Waynesboro, TN 38485. Your request must state the amendment desired and provide a reason in support of that amendment.

We will act on your request within sixty (60) calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request and provide access and copying.

If we grant the request, in whole or in part, we will seek your identification of and agreement to share the amendment with relevant other persons. We also will make the appropriate amendment to the health information by appending or otherwise providing a link to the amendment.
We may deny your request to amend health information about you. We may deny your request if it is not in writing and does not provide a reason in support of the amendment. In addition, we may deny your request to amend health information if we determine that the information:

a.	Was not created by us, unless the person or entity that created the information is no longer available to act on the requested amendment;
b.	Is not part of the health information maintained by us;
c.	Would not be available for you to inspect or copy; or,
a.	
d.	Is accurate and complete.

If we deny your request, we will inform you of the basis for the denial. You will have the right to submit a statement of disagreeing with our denial. Your statement may not exceed 3 pages. We may prepare a rebuttal to that statement. Your request for amendment, our denial of the request, your statement of disagreement, if any, and our rebuttal, if any, will then be appended to the health information involved or otherwise linked to it. All of that will then be included with any subsequent disclosure of the information, or, at our election, we may include a summary of any of that information.
If you do not submit a statement of disagreement, you may ask that we include your request for amendment and our denial with any future disclosures of the information. We will include your request for amendment and our denial (or a summary of that information) with any subsequent disclosure of the health information involved.
You also will have the right to complain about our denial of your request.

Right to an Accounting of Disclosures.
You have the right to receive an accounting of disclosures of health information about you. The accounting may be for up to six (6) years prior to the date on which you request the accounting but not before April 14, 2003.

Certain types of disclosures are not included in such an accounting:

a.	Disclosures to carry out treatment, payment and health care operations;

b.	Disclosures of your health information made to you;
c.	Disclosures that are incident to another use or disclosure;
d.	Disclosures that you have authorized;

e.	Disclosures for our facility directory or to persons involved in your care;
f.	Disclosures for disaster relief purposes;

g.	Disclosures for national security or intelligence purposes;

h.	Disclosures to correctional institutions or law enforcement officials;
i.	Disclosures that are part of a limited data set for purposes of research, public health, or health care operations (a limited data set is where things that would directly identify you have been removed.
a.	
j.	Disclosures made prior to April 14, 2003.
Under certain circumstances your right to an accounting of disclosures to a law enforcement official or a health oversight agency may be suspended. Should you request an accounting during the period of time your right is suspended, the accounting would not include the disclosure or disclosures to a law enforcement official or to a health oversight agency.
To request an accounting of disclosures, you must submit your request in writing to The current staff person, Vice President of Compliance, Buffalo River Services, Inc., P. O. Box 847, Waynesboro, TN 38485. Your request must state a time period for the disclosures. It may not be longer than six (6) years from the date we receive your request and my not include dates before April 14, 2003.

Usually, we will act on your request within sixty (60) calendar days after we receive your request. Within that time, we will either provide the accounting of disclosures to you or give you a written statement of when we will provide the accounting and why the delay is necessary.

There is no charge for the first accounting we provide to you in any twelve (12) month period. For additional accountings, we may charge you for the cost of providing the list. If there will be a charge, we will notify you of the cost involved and give you an opportunity to withdraw or modify your request to avoid or reduce the fee.
Right to Copy of this Notice.
You have the right to obtain a paper copy of our Notice of Privacy Practices. You may obtain a paper copy even though you agreed to receive the notice electronically. You may request a copy of our Notice of Privacy Practices at any time. At the agency's discretion, you may be charged a printing fee for the cost of reproducing a copy of the notice.
You may obtain a copy of our Notice of Privacy Practices over the Internet at our web site,
www.buffalo-river-services.com
To obtain a paper copy of this notice, contact The current staff person, Vice President of Compliance, Buffalo River Services, Inc., P. O. Box 847, Waynesboro, TN 38485.

Our Duties

Generally.
We are required by law to maintain the privacy of health information about you and to provide individuals with notice of our legal duties and privacy practices with respect to health information.
We are required to abide by the terms of our Notice of Privacy Practices in effect at the time.

Our Right to Change Notice of Privacy Practices.

We reserve the right to change this Notice of Privacy Practices. We reserve the right to make the new notice’s provisions effective for all health information that we maintain, including that created or received by us prior to the effective date of the new notice.
Availability of Notice of Privacy Practices.
A copy of our current Notice of Privacy Practices will be posted on the Announcement Bulletin Board at Buffalo River Services, Inc. Administrative Office and on the Announcement Bulletin Board at all other Agency locations. A copy of the current notice also will be posted on our web site, www.buffalo-river-services.com.
At any time, you may obtain a copy of the current Notice of Privacy Practices by contacting to The current staff person, Vice President of Compliance, Buffalo River Services, Inc., P. O. Box 847, Waynesboro, TN 38485.

Effective Date of Notice.
The effective date of the notice will be stated on the first page of the notice.
Complaints.
You may complain to us and to the United States Secretary of Health and Human Services if you believe your privacy rights have been violated by us.

To file a complaint with us, contact Phil Garner, Executive Director, Buffalo River Services, Inc., P. O. Box 847, Waynesboro, TN 38485. All complaints should be submitted in writing.

To file a complaint with the United States Secretary of Health and Human Services, send your complaint to him or her in care of: Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C. 20201.
You will not be retaliated against for filing a complaint.

Questions and Information.
If you have any questions or want more information concerning this Notice of Privacy Practices, please contact Phil Garner, Executive Director, Buffalo River Services, Inc.,
P. O. Box 847, Waynesboro, TN 38485.

II.	Historical Policies and Procedures Section 1: INTRODUCTION
Buffalo River Services, Inc. thanks you for your involvement with the agency and in supporting people with disabilities. BRS, Inc. is an agency that delivers quality services and supports to ensure and maintain the health, safety, welfare and quality of life for people with intellectual disabilities. BRS, Inc. is glad that you have made the choice to support people with intellectual disabilities and we look forward to working collaboratively together to assist people with intellectual disabilities.

Values are the principles that apply to all levels of the agency. The following values guide the day to day decisions that are made at BRS, Inc.
•	Honoring the individual rights of persons supported.
•	Focus on persons supported.
•	Effective service and support planning and coordination is crucial to the quality of life, health, and safety of persons supported.
•	Individual choices of persons are the foundation of service planning and delivery. It is incumbent on all individuals touching the lives of persons supported to ensure that they have the information needed to make informed decisions.
•	Opportunities to accomplish personal outcomes, live a meaningful life, and be included in the community are identified in the development and implementation of support plans.
•	Safety and security are essential to a person being able to achieve personal outcomes.
•	Risk identification and planning are vital to achieving a balance between allowing personal choice and protection from harm.
•	Respect of persons and the staff is crucial at all levels in the agency.
•	Professionalism of Agency staff is crucial to ensure the level of collaboration in the provision of services that result in achievement of personal outcomes. Expectations for achievement are high and it is expected that services are not intrusive or demeaning.
•	Person and family friendly information is necessary to promote understanding and choice.
•	Training opportunities for persons supported and their families are needed to ensure understanding and appropriate utilization of services.
•	Reliable and valid data and information must be easily accessible to all stakeholders to promote understanding of the system, identification of problems and issues and planning for effective ways of improving services.
•	Stakeholder input is essential to developing and maintaining systems that meet the needs of persons serviced from an operational standpoint and that ensure smooth implementation of changes in policy and operational procedure.
•	Systems change and quality improvement opportunities that benefit persons must be identified and implemented on an ongoing basis. Systemic issues, compliance issues, and individual problems must be identified, analyzed, and resolved in an organized, timely manner.
•	
•	Innovative approaches that ensure the best use of available public funds must be employed to ensure that the maximum number of people have access to needed services.
•	Compliance with applicable state and federal statutes, rules, regulations and policies is necessary to ensure that adequate funding is available to provide access to services.
•	Quality assurance monitoring must be focused on achieving desired outcomes and ongoing compliance.
•	Effective training opportunities are necessary to ensure that Agency staff achieve and maintain desired outcomes and compliance.
•	Fairness must be achieved and maintained in the provision of services.
BRS, Inc. is dedicated to serving people with disabilities in Wayne, Lewis, Perry, Lawrence, Hickman, Giles, and Maury counties and to supporting their families, caregivers and staff who deliver the supports and services necessary to promote their personal quality of life.

PRINCIPLES FOR THE AGENCY
I.	The Agency makes every effort to create opportunities for everyone, and to take care of each other. The Agency mission statement expounds on this value.

II.	The efforts that the Agency undertakes will always improve the quality of services to Persons Supported.

III.	Persons Supported satisfaction is of utmost importance. This will be defined by helping people get what they need and desire through the Person Centered Support Plan and from feedback from families.

IV.	Integrity regarding meeting state and federal guidelines is never sacrificed.

V.	Knowing Persons Supported is one of the single most important parts of every individual's job.

VI.	The focus of Buffalo River Services, Inc. is one of proactive planning and preventive management. Ours is a quality driven organization.

VII.	There is a great emphasis on training. Cross-Training is of paramount importance.
VIII.	The Agency will always pursue advance opportunities targeted on giving persons supported better direct care. Research and development are a priority.

The purpose of the BRS, Inc. Program Description and Program Policy Manual is to outline the basic principles and requirements for delivery of quality services to people with disabilities.

GOALS

The goals of the Agency are to provide comprehensive services to people with disabilities; to develop the most effective and appropriate services possible; to provide the opportunity for personal growth through independent work and living; and to offer the dignity of risk to all individuals with whom the Agency has contact.

The Agency acts as a coordinator. By acting as a coordinating agent, the Agency develops services for individual needs within the service delivery system. The Person Centered Support Plan will be based on information from the Person Supported and his/her family (if appropriate). The Agency provides services in, but not limited to, the following areas:
1.	Transportation
2.	Coordination
3.	Educational Training
4.	Health and Safety
5.	Employment Training
6.	Employment
7.	Informational and Referral
8.	Counseling
9.	Recreational
10.	Residential
11.	Social Services
12.	Family Support
13.	Nursing
14.	Occupational Therapy
15.	Physical Therapy
16.	Speech and Language Pathology
17.	Family Based
18.	Personal Assistance
19.	Community Living Supports
20.	Community, Facility & In-Home Day

THE AGENCY IS TOTALLY "PERSON CENTERED”.

PHILOSOPHY
To empower all Persons Supported to advance toward an enhanced quality of life as defined by each person.

MISSION STATEMENT

Buffalo River Services, Inc. will BUILD RELATIONSHIPS by establishing personal connections through community participation and individual settings.

Buffalo River Services, Inc. will REACH GOALS on individual levels to achieve a higher quality of life through employment, residential settings, or any personal need.
Buffalo River Services, Inc. will SUPPORT INDIVIDUALS by means of ensuring the rights of choice, respect, dignity, and understanding in a safe environment.

BUILDING RELATIONSHIPS REACHING GOALS SUPPORTING INDIVIDUALS

VISION STATEMENT
Buffalo River Services, Inc. will be one of the most recognized agencies in the field of disability services for going beyond the professional standards, upholding person-centered excellence, and being the bridge between people with disabilities and their communities. We will succeed because we see the ability in all.

MANTRA

Section 2: Program Services

Section 2: Policy 101 - ADVOCACY Policy:
BRS, Inc. is committed to making every effort in providing supports and services that meet and exceed the needs of people with disabilities in the community. As a proactive service provider and advocate, the agency will use every opportunity to affect changes that improve the quality of life of all people with disabilities in the community.
Opportunities are provided on an ongoing basis to empower Persons Supported, support staff, volunteers, and citizens of the community to express ideas and needs regarding supports and services available and needed. Agency staff are encouraged to act as advocates for people served on a daily basis through their interaction with the community. Individuals that express concerns or complaints can do so without retribution.

Procedure:
The Agency provides three methods for individuals to express and document concerns and complaints:

1.	The use of support planning meetings that will allow the documentation and systematic resolution of the concern by the Agency.
2.	The application of the Agency Grievance Procedure as the method to resolve a Persons Supported concern or complaint.
3.	The submission of the Request for Advocacy Services form to the Tennessee  Department of Disability and Aging (DDA) Regional Office. This action is determined by the Persons Supported Circle of Support for issues beyond the scope of BRS, Inc. advocacy.
Advocacy for persons served and support providers may also include the following forums:

•	Person Centered Support Planning Meetings
•	Agency Staff Meetings
•	Human Rights Committee Meetings
•	Board of Directors
•	People First Participation
•	The Arc
•	The Guidance Team Meeting (Every Person Supported, staff member, or family member, may request a hearing with the Guidance Team.)
•	
As a provider, BRS, Inc., recognizes that education for Persons Supported, support staff, volunteers, and citizens of the community is the key element to the development of a comprehensive program. The program may include:

-	Advocacy training provided by the Agency Director of Training may be included during Protection of Rights training.

-	Additional opportunities for advocacy training to be addressed will include the Circle of Support meeting and regularly scheduled staff meetings.

-	Staff orientation to the personnel policies regarding employee or Person Supported grievances.
DESCRIPTION OF SERVICES

BRS, Inc. operates several adult day programs, including community-based day support and employment services. A variety of options are available to meet Person Supported needs in Wayne, Lewis, Perry, Lawrence, Hickman, Giles, and Maury Counties. The normal hours of operation are 8:00 a.m. to 4:30 p.m., Monday through Friday.
The Agency operates a number of residential services consistent with Person Supported needs. Residential services include single room occupancy housing, residential services, medical residential and supported living. The hours of operation of the residential programs are approximately 3:30 p.m. till 8:30 a.m. the following morning and are staffed all day on Saturdays and Sundays.

Intended day service and residential outcomes include the following.

•	People are connected to natural support networks
•	People have intimate relationships
•	People are safe
•	People have the best possible health People exercise rights
•	People are treated fairly
•	People are free from abuse and neglect People experience continuity and security
•	People decide when to share personal information People choose where and with whom they live People choose where they work
•	People use their environments
•	People live in integrated environments
•	People interact with other members of the community
•	People perform different social roles People choose services
•	People choose personal goals People realize personal goals
•	People participate in the life of the community People have friends
•	People are respected
•	
Day Services:

Day Service supports include the principles of productivity, inclusion and independence while providing each Person Supported with training and support in the acquisition of, retention of, or improvement in daily living, social, communication, and vocational skills. Day services are structured so each person has the opportunity to discover his or her skills, interests, and talents in his or her community. Employment Services provide paid employment for Persons Supported who may require ongoing support with needed supervision to perform in the work setting.
1.	Community Based Services provide Persons Supported access to and participation in typical activities and functions of community life that are desired and chosen by the general population.

2.	In-Home Day Services are available to meet specific and well documented needs are to be used only in exceptional circumstances. These circumstances may include behavior or psychiatric destabilization, medical concerns/necessity, or other infrequent and exceptional circumstances. In Home Services are also provided to our People Supported that are living a retirement lifestyle.

Natural Supports in the Provision of Day Services
When natural supports are utilized in the provision of day services, the type and amounts of assistance provided by natural supports must be described in the PCSP and updated as needed during the monthly review process. Work-related natural supports are to be utilized only to provide on-the-job training and support that would be provided to any person hired in a similar position.

State funded day service can be billed for times during which natural supports are utilized if service provision and documentation requirements are met. Medicaid waiver services cannot be billed for times when services are provided by natural supports.

Natural supports are to be included in the Agency’s staffing plan. A job coach employed by the Agency must be available on call if needed to come to the work site immediately upon request from the person supported or the employer of the person supported.

Residential Services:
Residential service options are available to persons who are not able to live in home with family members. The residential service option will be one that meets the person’s needs and ensures the person’s health and safety. BRS, Inc. Residential Service options available are:
1.	Supported Living Services provides individually tailored services and supports that
1.	
enable a person to live and remain in his/her home in the community.
2.	Medical Residential Services provides the provision of health care supports.
3.	Residential Services provides a home-like environment that provides a home as well as assistance in acquisition of or improvement in daily living skills, personal grooming skills, food preparation, and social skills.

Community Living Supports:
Community Living Supports (CLS) is a community-based residential alternative service for seniors and adults with disabilities encompassing a continuum of support option for up to four seniors and adults with disabilities encompassing a continuum of support option for up to four individuals living in a home that supports each resident’s independence and full integration into the community, ensures each resident’s choice and rights and comports fully with standards applicable to HCBS settings delivered under Section 1915 (c), including those requirements applicable to provider-owned or controlled homes, as applicable, except as supported by the individual’s specific assessed need and set forth in the person-centered plan of care.

CLS services are individualized based on the needs of each resident and specified in the person-centered plan of care, but may include hands-on assistance, supervision, transportation and other supports needed to help the individual:
•	Select and move into a home;
•	Locate and choose suitable house mates;
•	Acquire and maintain household furnishings;
•	Acquire, retain or improve skills needed for activities of daily living or assistance with activities of daily living as needed, such as bathing, dressing, personal hygiene and grooming, eating, toileting, transfer and mobility;
•	Acquire, retain or improve skills needed for instrumental activities of daily living or assistance with instrumental activities of daily living as needed, such as household chores, meal planning, shopping, preparation and storage; managing personal finances;
•	Build and maintain interpersonal relationships with family and friends;
•	Pursue educational goals and employment opportunities;
•	Participate fully in community life, including faith-based, social and leisure activities selected by the individual;
•	Schedule and attend appropriate medical services;
•	Self-administer medications, including assistance with administration of medications as permitted pursuant to TCA 68-1-904 AND TCA 71-5-1414;
•	Manage acute or chronic health conditions, including nurse oversight and monitoring, and skilled nursing services as needed for routine, ongoing health care tasks, such as blood sugar monitoring and management, oral suctioning, tube feeding, bowel care, etc.;
•	Become aware of and effectively use transportation, police, fire and emergency help available in the community to the general public; and
•	Assert civil and statutory rights through self-advocacy.
•	
Member file should include a minimum of:
•	DNR
•	Emergency Plan
•	CC and family contact information
•	MCO CLS Daily Notes
•	Travel Log/Activities
•	Member Specific Plan of Care
•	Risk Agreement
•	Medication Agreement
•	MAR
•	Any outpatient therapy services provided within the home/provider follow-up form

Other Services:
1.	Respite Services can be provided in a residential setting including supportive living
and cannot exceed the home’s licensed capacity.
2.	Nursing Services will include a nursing plan of care which is consistent with action steps and outcomes specified in the PCSP. The nursing plan of care will include the amount, frequency and anticipated duration of services required.

3.	Personal Assistance Services provides necessary assistance for eligible individuals in order to meet their daily living needs and facilitate participation in the community.

4.	BRS, Inc. maintains a Professional Support Services License for the provision of Nursing, Occupational Therapy, Physical Therapy and Speech Language Pathology Services. Services are provided in accordance with the approved PCSP and Clinicians Plan of Care.

Section 2: POLICY 102 - RECORDS

Policy:
The Agency will create a record containing documentation of services provided for each person.

Procedure:
Comprehensive records, day service records, respite and personal assistance record will be maintained on the agency TIMAS database. Residential/Supported Living locations also
have access from the home to this database. Administrative and Personnel Records are also maintained on the agency database.
•	Any paper records will be locked to maintain confidentiality.
•	Records will be maintained for a period of ten years from the date of death or
•	
discharge.
•	The previous twelve months is to be maintained in the active file.
•	Records relevant to services provided during the past two to ten years will be kept in archived files.
•	The Agency will maintain original documents electronically, other than SS Card/Insurance Card/Birth Certificate. Those will be maintained paper and electronically.
•	The Agency will maintain Reportable Incident Forms (RIFs) in an administrative file
separate from the person’s records, if applicable
•	Persons’ records are made available upon request to the person, the person’s legal representative, family members or other individuals who have obtained appropriate consent for access to the record, service providers involved in the provision of services specified in the PCSP, DDA, TennCare, and staff of other state and federal agencies with authority to conduct monitoring or other related activities.
•	The Agency will also maintain administrative and personnel records for a period of ten years. Administrative records include financial records, written policies and procedures, board or advisory group appointments, and committee members.
•	The Agency will comply with DDA records requirements as outlined in Provider Manual Chapter 10; March 15, 2014.
•	For Choices individuals, the record will contain at minimum; DNR (if applicable), Emergency Plan, CC and family contact, Daily Notes with travel noted, Plan of Care, Risk Agreement & Medication agreement (if applicable), MAR/Therapy/Medical appointments/information.

Section 2: POLICY 103 – ADMISSION

Policy:
People requesting services provided by BRS, Inc. will have been determined eligible for services by DDA or will be required to complete and submit the Initial Service Request to the regional DDA office.

Procedure:
BRS, Inc. will accept referrals for people with disabilities to existing services consistent with eligibility guidelines, programmatic needs, and waiting list limitations. Referrals will be provided by contracted agencies that provide referral and case management services.
All referrals for admission will be conditional, contingent upon the Agency's capability to provide appropriate services based on individual needs, and within funding provisions.
The Individual Comprehensive Assessment Plan (ICAP), Supports Intensity Scale (SIS) or a similar document will be completed on individuals prior to admission.

Policy Statement and Purpose:	
Buffalo River Services, Inc. is willing and able to support individuals who have been referred by a Managed Care Organization (MCO) and/or have selected Buffalo River Services, Inc. Persons supported will receive orientation to services, which is designed to assist persons supported to make informed choices during the process of provider selection.	
Procedures:	
A.  Referrals	1.	Buffalo River Services, Inc. will consider all ECF CHOICES referrals received from any health plan or MCO.
2.	Referral acceptance or denial is based on the availability of staff, or for CLS referrals, a current residence that fits the desires and preferences of the individual being referred or if the identification of an affordable house/apartment in the desired geographical location. If the individual being referred has a home, but only needs support, our acceptance or denial will be based on the availability of support staff or a particular needed expertise. A target to achieve with a marginal rate of variation and standard deviation of plus or minus several degrees dependent upon several potential variables can be 85%. However, circumstances will always affect this ability. As appropriate to the individual and their supports, fading services will always be a consideration as needed.
3.	Buffalo River Services, Inc. assists individuals with the provider selection process by meeting with them to share information about services and supports offered by the agency including, but not limited to:
a.	Transportation is offered to individuals who wish to meet for the purpose of considering which provider to choose.
b.	Transportation is offered to individuals who wish to visit the specific residence(s) the provider has available.
c.	Work with the support coordinators to facilitate opportunities for the persons supported to see the home and to meet other potential housemates to determine compatibility.	
B. Pre- orientation supports	1.	For employment and community-based services accepted, Buffalo River Services, Inc. will initiate the authorized services as indicated:
a.	If Buffalo River Services, Inc. has an existing home(s) where another individual already lives, an initial visit will be arranged as soon as reasonable, within 10 business days if possible, for introduction purposes to start to determine compatibility. Also considered is the desired geographic location for the person referred.
b.	If Buffalo River Services has or knows of a desirable home that does not have any current residents, or where residents will be moving out of in the near future, Buffalo River Services will work with the MCOs to identify, individual(s) who would be compatible housemates and have interest in living in the geographic area where the house is located.
c.	CLS home may be a “blended” home of individuals supported by
DDA and ECF CHOICES, individuals supported through CHOICES	

	and ECF CHOICES or only individuals supported through ECF CHOICES. Each home is developed granting as much consideration as possible to meeting the preferences and desires of each individual.	
C. Orientation	1.	Buffalo River Services will provide an orientation to the member/family in person prior to or within the first 5 days of service delivery where the scope of authorized services and expectations of both the individual/family and Buffalo River Services staff are outlined, and all questions answered. If the orientation needs to be scheduled after 5 days to accommodate the presence of a family member or due to an unusual circumstance (accident, illness, etc.), the reason for delay will be noted on the ECF CHOICES Referral, Orientation and Plan Implementation Timeline and the log maintained by the Co-director of Residential Programs.
2.	The person supported and all members of the Circle of Support (COS) will be provided with the Person Supported form, Complaint Resolution Procedures form, contact name and phone numbers, service definition and Buffalo River Services, Inc. brochure. which includes contact names and phone numbers, and service definitions). The person supported/family will be asked to sign and date that they have received the orientation materials.
3.	The person supported and the Direct Service Professionals (DSPs) that will support the individual will begin services with an initial implementation plan to define parameters of the authorized services,
4.	Buffalo River Services, Inc. orientation may include accurate and accessible information about how to learn more about self-advocacy and supported decision making. (Exemplary Practice Indicator 3.a.5)	

BRS, Inc. New Admission Checklist

Person’s name 	Date	 (Write completed and add date when completed on line)
Staff person completed list	 Meet and greet current residents. 	

All forms for history procured:		 Psychological			 Recent Medical reports		  Medication prescriptions		  Social history			 School records			  Person-centered plans				  Social Security and Medicaid cards procured and stored					  Risk assessment completed				  Human Rights reviewed and checklist completed				  Medication on hand for the next 7 days					  Listing of any known allergies				 Listing of all nutrition needs					 Special diets	
Special food prep and menus	 Furniture procured			  Representative payee processes and banking account established			 Person centered tools administered		 Family given orientation to rights and responsibilities				 Safety orientation given to new person and first fire and tornado drills done in 1st day					
In the case of someone seriously impaired and unable to evacuate on their own, a emergency evacuation plan must be written prior to admission. It will include use of fire blankets, procedures to get the person out and in what order. Plan will be written and training for all staff completed prior to person moving in.
Personal data stored and TIMAS entered	 Personal inventory list made of all personal items	

Personal inventory will be witnessed by two people and signed. The list may be entered below.
Items:

		

		

		

		

		

Section 2: POLICY 104 - ASSESSMENTS
Policy:

BRS, Inc. will assist people receiving services in the acquisition of assessments as necessary to determine individual abilities and service needs.
Procedure:
The assessment process will focus on recommendations by support providers and appropriate professionals and will be reviewed as required. The process will also concentrate on the person’s current disability and the effects of any contributing disability.

Section 2: POLICY 105 - SCHEDULE OF FEES
Policy:

BRS, Inc. contracts with the State of Tennessee and other public and private organizations to provide funding for a portion of the support services provided. In some cases, persons supported are required to contribute a portion of their income to support the service provided.

Procedure:

BRS, Inc. day services charges no fees other than the funding level agreed upon by the Agency and the State of Tennessee or Private or Public Organization.

For individuals receiving residential services, the person’s cost is no more than 80% of their SSI.
For fees associated with transportation, see Transportation Policy.

Section 2: POLICY 106 - SUPERVISION
Policy:

Unless otherwise specified on the persons supported service plan, it will be the policy of BRS, Inc. to provide sufficient person supported supervision and oversight.
Procedure:
Supervision shall include the staff-to-person supported ratio consistent with cost plans, agreements for services, state statute(s), licensure, cost plan summary, and staffing plans based on the needs of each Person Supported. For example:

Day/Support Services
-	Level 1-3 Community Based Day Services, 1 staff to 3 persons supported
-	Personal Assistance 1 staff to 1 person supported
-	Supported Employment, as determined by funding requirements

Residential supervision of persons supported will be as specified by the requirements of funding agreements, cost plans, and defined circumstances for staffing pattern ratios. Residential ratios will be identified in cost plans and staffing plans. Staffing plans outline the level of staffing that is needed for residential and day services for the person.
Supervision and oversight will be provided consistent with each person's rights. Refer To:
Provider Agreement Individual Cost Plan(s) Cost Plan Summary Human Rights Policy Licensure Requirements Staffing Plans

Section 2: POLICY 107 – HOUSE SELECTION
Policy:

People will live with whom and where they choose.
Procedure:

BRS, Inc. does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by law. BRS, Inc. complies with Title VI in the provision of all services.
All bedrooms are private bedrooms. When a room opening occurs, the Circle of Support addresses any safety issue, stability, or physical condition that may warrant the use of the room. If none of the above concerns are present, the individual with most seniority will get the room of his/her choice.

Section 2: POLICY 108 – PETS
Policy:
Residential and supportive living persons supported may have pets.
Procedure:
Residential and supportive living residents may have pets for a $25.00 deposit. The person supported will be responsible for the pet’s vaccinations, veterinarian bills, grooming, purchasing of food, and feeding of the pet. The person supported will also be responsible for any necessary cleaning (i.e. carpet and floors) if the pet has accidents that cause odors and stains. If the pet damages the home, the person supported will be responsible for repairs. Landlord approval is needed when applicable.

Section 2: POLICY 109 - TRANSPORTATION
Policy:

BRS, Inc. shall provide safe and reliable transportation services for person supported consistent with their needs and within the resources available to BRS, Inc. Assistance may also be provided to access alternative types of transportation as identified in the Person Centered Support Plan.

Procedure:

Vehicle Operators will possess the appropriate license for the type of vehicle and capacity as required by the Tennessee Department of Safety and Homeland Security. Additional requirements include training identified in BRS, Inc. training policy as well as issues related to safe vehicle operations.
Persons supported who require BRS, Inc. transportation programs will be provided services consistent with the Person Centered Support Plan and based on needs related to issues regarding safety, specialized equipment, outcomes, environment, quality of life, and supervision, within the resources available to BRS, Inc. Insurance on BRS, Inc. vehicles will be maintained to meet or exceed the minimum contract requirements. A Certificate of Insurance or other acceptable documentation will be required from the employee or volunteer for personal vehicles used for Agency business.
Maintenance of Agency vehicles will be consistent with the requirements of the manufacturer as well as additional needs related to specialized equipment to ensure safe mechanical operations. Vehicle interior and exterior will be cleaned as needed on a regular basis by staff and/or individuals served, and repairs will be completed in a timely manner by a competent professional.

Vehicles with wheelchair access will comply with applicable requirements as well as possess equipment necessary to ensure safe attachment of each wheelchair(s) during operation.

Operation of BRS, Inc. transportation services may be limited or discontinued during inclement weather as determined by the Chief Executive Officer or designee.

In the provision of day services, the State of Tennessee reimburses the Agency for a round- trip from home to the center and back to home, once per day, up to 30 days per month, for Medicaid Waiver-funded clients.

Transportation is provided for Community Based services and Personal Assistance services within reason. Trips out of town for recreational and/or vacation events are not provided by the Agency, but must be paid for by the persons supported. Staff attending the Independent Support Plan (PCSP) Meeting are expected to make the Independent Support Coordinator. Care Coordinator, Support Coordinator (ISC) and Circle of Support aware of this policy so that the Circle can determine if the person supported can financially afford the outcomes noted in the PCSP.
Transportation is provided for residential programs for area grocery shopping and recreational events in town. Residential programs can make one trip out of town each weekend within a 50-mile radius with prior approval of the Program Director. In lieu of an out-of-town trip, programs may elect to take a drive within that same radius. Trips that exceed the definition above must be pre-approved by the Chief Executive Officer or his designee.
Trips to medical appointments for persons supported requiring 24-hour staffing will be provided. Additional funding should be acquired from the DDA Regional Office for out-of- town trips that require individual staffing if a Person Supported is not already staffed at that ratio.

Persons supported who are not in Agency care 24 hours are encouraged to use public transportation or their family members for their medical appointments. The Agency will provide medical transportation under certain conditions. Additional funding must be sought from the Person Supported, family, or DDA Regional Office. Additional staffing is usually an issue for the Agency, and a two-week notice prior to the appointment date is required. Appointments should be made to accommodate the hours that the Agency provides transportation, which is normally Monday – Friday, 8 a.m. until 4:30 p.m.
Persons supported transported by the Agency are expected to abide by Agency policies and procedures, and behavior should be respectful to others at all times.

Only bottled water is allowed to be opened and consumed in Agency vehicles. All other foods and drinks are not allowed. They can be transported to a destination but not opened and/or consumed while in the Agency vehicle.

Section 2: POLICY 110 - ACCOUNTING FOR PERSONAL FUNDS
Policy:

BRS, Inc. will provide assistance with funds management and supervision that is consistent with the needs, choices, and circumstances of persons supported as stated in the Person Centered Support Plan (PCSP). Management and evaluation of accounts will be provided as required by OMB-133A.
Refer To:
Government Auditing Standards, Office of Management and Budget (OMB) State of Tennessee Comptrollers Guidelines
DDA Personal Funds Management Policy Participant Financial Assurance

Procedure:
The Chief Executive Officer or designee will provide appropriate assistance to persons supported to maintain accountability for their funds and or property. The ISC will be responsible for the development of all financial resources required to support the PCSP of each Person Supported.

As fiduciary guardian, the Agency will comply with applicable regulations. Each persons supported account will be at a FDIC or SBIC insured financial institution with access to funds consistent with the financial institution policy. Each checking account will have pre- numbered checks, and transactions will be documented. A transaction summary will be provided as required.

Persons supported involved in employment programs will be paid consistent with Department of Labor standards.

Persons supported sometimes choose to cash their paychecks, otherwise, all income will be deposited into the person supported’s account(s) in a timely manner. Electronic transactions will be encouraged for all deposits.
All persons supported finances will be maintained on the agency database. Staff are responsible for documenting/updating daily.

The misuse of a persons supported funds or property by staff or volunteers is prohibited and will be grounds for disciplinary action, up to and including termination.

Employees may not make personal long-distance phone calls at homes of persons supported unless they bill the call to their own phones or use a phone card. Any long- distance calls made on behalf of person supported must be documented on a phone log including the name of the person called, the number, and the reason. Individuals are

responsible for their own long-distance calls.

The Person Centered Support Plan shall address:
1.	How the Person Supported personal funds will be managed;
2.	The Person Supported capabilities and desires regarding personal funds management;
3.	Any training or assistance needed to support the Person Supported in managing personal funds or to develop skills needed to increase independence with managing personal funds;
4.	The extent to which personal funds will be managed by the Agency or conservator (earned and unearned funds, including trust funds).
5.	Goals and objectives involving use of the Person Supported personal funds;
6.	Any health, safety or exploitation issues that require limitations on access to personal funds and strategies to remove limitations at the earliest possible time;
7.	The Person Supported desire, if applicable, to have a separate bank account rather than an agency-controlled account for personal funds; and
8.	The person’s desire, if applicable, to have a joint bank account and share
expenses with the person’s spouse.
The agency is required to notify the Independent Support Coordinator. Care Coordinator, Support Coordinator of changes in the Person Supported personal funds that would require a change in the PCSP or that would affect implementation of actions required to meet the goals and objectives specified in the PCSP.
The agency will ensure that:
1.	Person Supported who are capable of managing their own personal funds are supported to the extent needed to do so;
2.	Person Supported who desire greater involvement in management of personal funds but have skills deficits are provided appropriate personal funds management training in accordance with the PCSP.
3.	Person Supported who are unable to manage their personal funds may choose another person to act on their behalf (Person Supported receiving Social Security may complete forms to designate a Representative Payee).
4.	For a Person Supported who has been declared incompetent for the purposes of money management, the legal guardian or conservator is given the choice to manage the person’s personal funds or to choose a person or entity to act on the person’s behalf in managing such;
5.	Reasonable efforts are made to identify a responsible “Representative Payee” who is a family member or friend of the enrollee and that the provider is utilized as the “Representative Payee” only if another responsible party cannot be identified. The PCSP must address this and identify the selected “Representative Payee”;
6.	Person Supported are not required to designate the agency as “Representative Payee” as a condition of receiving services
7.	The Person Supported will not be charged a funds management fee when the
agency is selected as the “Representative Payee”.

8.	When the agency is chosen to act as “Representative Payee”, the name of the legal guardian or conservator and the circumstances of the appointment are noted on the Social Security Administration application form (Form SSA-11, page 1, item 5) so that the guardian or conservator may be contacted if necessary.
The Agency, employees, representatives, subcontractors and paid conservators are prohibited from illegally obtaining or otherwise misusing personal funds, including but not limited to:

1.	Borrowing personal funds from the Person Supported;
2.	Using a person supported’s personal funds for staff benefit (i.e. purchasing premium cable channels for staff entertainment or purchasing tickets for staff attendance to activities or events selected based on staff preference rather than Person Supported preference, purchasing caller ID or other features that benefit staff and not the Person Supported);
3.	Using a person supported’s personal funds for agency benefit, paying for maintenance or repair to buildings or appliances owned by the agency, or for telephone charges for an agency telephone or office space intended for provider use (office space is defined as a room or significant portion of a room designated for staff use and not consistently accessible to the person served. A personal computer and a telephone shall not be considered an office if the Person Supported is allowed access to the area of the home);
4.	Using one Person Supported funds for the benefit of another person;
5.	Using personal funds for any medical supplies, services or equipment covered by TennCare, Medicaid, Medicare or other health insurance.
6.	Giving or withholding a person supported’s personal funds for the purpose of rewarding or punishing the person supported unless specifically approved by the Human Rights Committee and specified in the PCSP; and
7.	Otherwise using the person supported’s personal funds for purposes that do not benefit the person.

Personal funds are not commingled, including:
1.	Ensuring that person supported personal allowances kept in the homes are maintained separately and are not treated as household petty cash. (If a single locked box is used, the personal allowances must be kept in separate labeled envelopes within the box.)
2.	Ensuring that separate ledgers are kept for each person, including beginning and ending balances for each month and a description of any expenditures (with supporting receipts for expenditures exceeding $5.00); These ledgers are maintained on the agency database.
3.	Maintenance of separate bank accounts for each Person Supported, documentation of monthly reconciliation of bank statements, checks and deposits, and prohibition of negative bank balances.

There is timely reimbursement (not to exceed 30 days) to the Person Supported following

identification of a financial loss to the person caused by the action or inaction of the Agency or Agency employee, representative or subcontractor, including but not limited to:

1.	Loss of Social Security funds due to Agency negligence in allowing countable assets to exceed the countable asset limit;
2.	Payment of bank fees for insufficient funds that result from Agency negligence;
3.	Late payment penalties to utilities; and
4.	Payment of expenses that do not directly benefit the person;

When BRS, Inc. is the Representative Payee, the Agency will assure consistent availability of current information involving the following:

1.	The amount of financial resources available to each Person Supported for basic living expenses and for personal spending.
2.	The amount of total countable assets (for Medicaid funded enrollees, personal assets exceeding maximum resource limits must be reported to the Department of Human Services); and
3.	Documentation (i.e. receipts, monthly billings, checkbook ledgers) of expenditures made on behalf of the Person Supported, including justification that the purchase was appropriate and in accordance with the person’s needs;
Insurance policies for persons supported must be for the sole benefit of the Person Supported and Person Supported will not purchase home liability insurance for agency owned property or as a condition of receiving services.

All personal funds and personal property are appropriately inventoried or accounted for in the agency database; including:

1.	Initial inventories of personal property compiled as of the date the provider began providing services;
2.	Timely updating of inventories of personal property to indicate personal property removed from or brought into the home, including dated signatures of the individuals who purchased or supplied the personal property;
3.	Timely updating of personal funds or personal allowance ledgers to indicate funds provided to the Person Supported by others, including dated signatures of the individuals who supplied the funds;
4.	These additions/deletions will be addressed in the Team Meeting and documented in the Team Minutes; and
5.	The log of property will be available upon request and it will be kept in each
person’s file.
Personal property and personal funds are efficiently and effectively transferred in a timely manner to the new provider when a change of providers occurs, including but not limited to:
1.	The transferring provider shall reconcile records pertaining to the personal funds
1.	
management (personal allowance ledgers, checkbooks, etc.);
2.	Except as otherwise required by Social Security requirements, the transferring provider shall forward any personal allowance cash balances to the receiving provider within five working days;
3.	The transferring provider shall provide the receiving provider with an inventory of the person supported’s personal property, as well as the actual personal property if a change in location is necessary (includes all items purchased with state establishment money on behalf of the Person Supported);
4.	The receiving provider shall conduct an initial inventory of all personal property received and immediately notify the transferring provider and the Independent Support Coordinator. Care Coordinator, Support Coordinator if there are any discrepancies between personal property received and personal property noted on the transferring provider’s inventory;
5.	Except as otherwise required by social security requirements, the receiving provider shall complete arrangements to transfer benefit payments (food stamps) within five working days; and
6.	If applicable, the receiving provider must complete and submit documents necessary to establish the receiving provider as the representative payee within thirty calendar days.

LEASES
The agency will assure that supportive living Person Supported rents and leases do not exceed fair market value for other similarly situated property in the same general location and that the term of the lease agreement does not exceed one year and that at least a one- month notice is required from either party to terminate, unless specified in the PCSP and unless written agreement has been obtained from DDA. Also, no more than one-month deposit can be required.

Any cash expense should be logged in the cash log noting use and cash returned will be logged on the cash log. persons supported will not accumulate in the home the excess of
$100.00 unless the PCSP specifies that the Person Supported desires to save money, in which case the excess shall be deposited into a bank account in the person’s name, at the bank of their choice. Staff will ensure that the accumulation of these funds does not result in loss of benefits (Social Security, Medicaid eligibility, etc.)

If a Person Supported makes a group purchase (i.e. purchase of pizza that more than one Person Supported will consume) each Person Supported is charged a prorated amount consistent with usage/consumption. Receipts must be maintained for group purchases of
$5.00 or more.

Section 2: POLICY 111– RESIDENTIAL AND SUPPORTED LIVING PERSON SUPPORTED FUNDS
Policy:

BRS, Inc. will provide assistance with funds management and supervision that is consistent with the needs, choices, and circumstances of People Supported as stated in the Person Centered Support Plan (PCSP).

Procedure:
1.	A designated staff working in the home will be responsible to assist and train the Person Supported to pay bills accordingly, manage their money, and provide supervision on grocery shopping and supplies purchased.

a.	Team Leaders will be responsible to check weekly the cash flow of the Person Supported in the home.
b.	Team Leaders will notify the Program Director of any problems a Person Supported is having due to bills being high or need of groceries, etc.

c.	The designated staff writing a check to support a need of the Person Supported /she is supporting will initial the check.
d.	If staff write a check for a Person Supported and the funds are not available, the staff will be responsible to pay the fee out of their own pocket. Failure to notify the Program Director and, ultimately, the Vice President of Compliance of Person Supported financial needs will be grounds for disciplinary action.

e.	Any expense over $50.00 will have prior review by the entire team. Person Supported may choose to purchase anything at or above this cost if they have the funds available. Reviewing is to ensure the staff follow-up with proper techniques. This review will be documented in the Team Minutes. Although $50.00 is not the set limit of an item that must be logged into the consumers personal inventory, all items that cost this amount must be logged. There are some items that cost below this amount that should also be logged on the personal inventory (i.e. CD Players, Radio’s, etc.).

f.	Any cash purchase over $5.00 needs a receipt with staff’s initials on it. This receipt must be posted in a timely manner to the cash log (i.e. the day of the purchase of the very next morning, if late evening).

g.	Staff will be responsible to replace any funds for purchases without documentation behind them.
h.	The Program Director or designee will be responsible to do the bank reconciliation for his/her unit and for reconciling the cash logs monthly.
i.	Backs of statement are to be filled out with staff initial. The checkbook is to be highlighted and initialed upon reconciliation.

j.	The Vice President of Compliance will be spot-checking checkbooks and cancelled checks monthly.
a.	
k.	The Program Director will review all cancelled checks monthly.
2.	All checks written must have a supporting receipt filed with the check number noted. All receipts will be filed by Person Supported by month. At the end of each month, all files will be turned in to the administrative office for safekeeping. If anything is purchased by or on the behalf of a Person Supported that needs to be returned to a vendor (Wal-Mart, etc.), the old receipt and the new receipt (if something was purchased to replace it) must be kept. If cash is returned and not spent, cash must either be logged into the cash log, or, if a large amount of money is returned, an immediate deposit must be made to the person’s checking account. When the Program Director or designee reconciles the bank statement monthly, he/she must also check receipts and checks to ensure proper receipts are being kept.

Misuse or abuse of Person Supported money can and will be grounds for disciplinary action, up to and including termination. If staff are found to have intentionally misappropriated or stolen Person Supported funds, the staff will be reported to the DDA office of investigations and possibly the Attorney General for prosecution.

Section 2: POLICY 112 – WAITING LIST
Policy:
BRS, Inc. will assist other agencies within the service delivery system in identifying people in need of services.

Procedure:
BRS, Inc. will identify and coordinate case finding activities with other agencies, such as Tennessee Department of Human Services, Employment Security, Regional Office of the  Department of Disability and Aging, Public Health, local Mental Health Centers, Independent Support Coordination Agencies, local public school systems, police departments, local Arc., etc.
BRS, Inc. will assist in locating needed services, including informing individuals and their families of available services and assisting individuals in entering the service delivery system. This will be done through periodic contact and communication with relevant social service agencies and local professional and service organizations.

BRS, Inc. will advise all potential referral sources of the services provided by the Agency, participate in meetings which involve others in the service delivery system, list the Agency in appropriate directories, produce and distribute informational pamphlets regarding the services provided by the Agency, and conduct tours of the facility for interested citizens.

Section 2: POLICY 113 - RESPITE SERVICES
Policy:
BRS, Inc. will assist the Person Supported or their parent /guardian, Independent Support Coordinator. Care Coordinator, Support Coordinator (ISC), or other support provider in applying for respite services.
Procedure:

When it is determined that a Person Supported has a need for respite services, BRS, Inc. or the family will contact the ISC immediately.	BRS, Inc. is a licensed respite provider and should be contacted for availability of respite services. The ISC will also contact the DDA Regional Office for assistance in determining resources.
The ISC will be responsible for coordination for admission to respite services, pre-admission meeting, and ensuring that needed records and personal belongings arrive for the person.

The ISC will be responsible for any coordination and transition services required to ensure that the return to the community will occur in an orderly sequence. Additional follow up services may be needed as determined by the ISC.

Section 2: POLICY 114 - DISCHARGE
Policy:

It shall be the policy of BRS, Inc. that all efforts are made to develop the potential of the person served as much as possible. Thus, all decisions for discharge from services shall be made with the potential benefit of the person in mind.

Procedure:
When BRS, Inc. is no longer the service provider of greatest benefit or the Person Supported requests a change, the Independent Support Coordinator. Care Coordinator, Support Coordinator will be contacted for referral to the appropriate agency of greater potential benefit. Follow-up services will be provided to ensure the smooth transition of the Person Supported to another program.

Discharge will be for one or more of the following reasons:

1.	If, after Agency program evaluations/assessments are administered to measure development, the team does not feel an individual program plan can be devised to meet the person's needs, the person shall be discharged, being given 30 days’ notice. The
1.	
agency will continue providing services until another provider is identified.
2.	The skill level of the person has increased to the point that the program is unable to further raise it and the Person Supported appears to have potential for further development or the fact that the Person Supported can be referred to a more appropriate program.

3.	The person supported’s behavior becomes such that the safety of the person supported, other person supported, and the staff are imminently threatened with serious bodily injury. Behavior control programming has been instituted and failed. It is possible for a person to be discharged from residential services and remain in the day program. It is possible to discharge someone from the day program and they remain in the residential program if other day services can be provided.
4.	Medical management problems are such that the Person Supported is not able to participate in the program.

5.	If a person supported no longer requests services, he/she will be discharged, effective the last day of services.
6.	The person supported is no longer able to meet funding eligibility guidelines.

7.	A person supported may be discharged if he/she misses in excess of 30 consecutive calendar days.
8.	The Agency will write a discharge summary report and file in the person’s record thirty days after day of discharge.

As required in the Provider Agreement, prior to discharge, BRS, Inc., will provide at least thirty calendar days’ notice to the person served, the parent/guardian, the support coordinator, and the regional office. A hearing may be requested by the Person Supported or representative in accordance with TCA 33-1-202 (2.c.1).
BRS, Inc. will comply with DDA Operations Manual rules requiring the approval of the Regional Office and Central Office of the  Department of Disability and Aging or court order in the event of an appeal. Consultation will be provided as requested to develop a discharge plan.
The final decision for discharge lies with the Executive Director.

Section 2: POLICY 115 – HEALTH CARE REQUIREMENTS
Policy:
BRS, Inc. will provide supports and assistance consistent with the needs of each person to maintain good health as well as supports and guidance that promote good health.

Communication will be established and maintained with health service providers to ensure that the optimal services are provided as well as monitoring the need for supplemental services and access to these services. The management of health needs may also include monitoring, medication, durable medical equipment, activities, diet, and other related activities as required and within the scope of services available.

Records relating to each person supported’s health care needs will be maintained consistent with the needs of each person and contract requirement. Emergency medical information will be available to locations serving individuals with high health needs.
Pertinent information regarding support needs will be included in each person’s PCSP.
Procedure:
BRS, Inc. will provide the following services to meet the health care requirements of Person Supported:

-	Person supported’s medical information will be available in the main record (database) as required by contract and applicable regulations.
-	All medical information is classified as CONFIDENTIAL.

-	The medical records or supplemental information is on site in agency database, in the event of medical emergencies for persons supported with medical needs.
-	Development of relationships with health care providers and support providers to ensure that each Person Supported receives the optimal benefit of basic and supplemental services.

-	Staff training that includes recognition of medical problems and appropriate interventions. Training will include the operation and maintenance of specialized equipment as required.
-	Training on First Aid and CPR procedures and when to initiate First Aid. First Aid and CPR training provides instruction on when a 911 call must not be delayed.
-	Development of Medical Emergency plans that include input from support providers and available to support providers and PCP as required.

-	Timely access to health care services for Person Supported. All appointments and health care encounters including follow-up recommendations by the treating practitioner are arranged and attended in a timely manner.

-	Ongoing review, evaluation, and intervention of health needs.
-	Accessible transportation is available for all health care encounters, medical, dental and other appointments (Residential/Supported Living).
-	
-	The person is adequately supported to attend the health care encounter and/or appointment (Residential/Supported Living).
-	Appointments and health care encounters and all recommendations appropriately documented.
-	Outcomes from appointments and health care encounters are communicated to the legal representative, if applicable, and the ISC/CM.
-	Documentation of all supports provided to assist the person and or legal representative to obtain the examination if the person and or legal representative refuses.

Section 2: POLICY 116 – PROTECTION FROM HARM

Policy:
BRS, Inc. will assure the safety, protection and personal freedom of people supported.

Procedure:

BRS, Inc., Inc. is responsible for the designation of an Event Management Coordinator (EMC) and maintain a Provider Reportable Event Review Team.
Event Management Coordinator responsibilities include:
1.	Provide oversight of agency reportable event management processes and the implementation of risk mitigation strategies that support people in making informed choices
2.	Monitor event reporting, ensuring consistent compliance with timeline requirements per operational protocol.
3.	Review all agency reportable events, final investigative reports, action plans and informational findings collaboratively with DDA and Managed Care Organizations (MCOs).
4.	Evaluate PRERT recommendations on a regular basis, bringing any observations to the PRERT for revisions that may be needed.
5.	Perform data tracking and trending analysis regarding all reportable events and investigations.
6.	Document, perform data collection and trend analysis, and address all non-reportable
events internally as part of the agency’s quality improvement processes.
7.	Facilitate the PRERT meetings by presenting applicable cases, relevant data analysis, quality improvement strategies, and ongoing follow up to the PRERT.
8.	Ensure that new and existing staff are trained on the Reportable Event Management process and applicable agency policies and procedures.
1.	
9.	Complete, disseminate, and maintain documentation for PRERT meetings that summarize team discussions, action steps with identified responsible owners, and timelines for accountability per agency policy.

The Provider Reportable Event Review Team represents a comprehensive approach to reviewing reportable events. PRERT responsibilities include:
1.	Review reportable and non-reportable event trends and reports as presented by the EMC.
2.	Use tools such as data analysis to identify barriers, risk mitigation strategies and opportunities for quality improvement.
3.	Collectively develop recommendations that utilize proactive practices that result in the desired outcome and prevent or reduce the likelihood of future similar events.
4.	Revise recommendations based on evaluation of implemented actions.
5.	Review agency policies and procedures annually and as needed to reflect process improvements.
6.	Contribute to fostering a culture of learning and is not punitive when a reportable event occurs.
7.	The Provider Reportable Event Review Team will meet regularly but no less than monthly.
8.	Meetings will be documented and will reflect discussion and follow up actions concerning reported events and investigations, their causes, actions taken, and recommendations made by the review team.
9.	Provider oversight for reportable and non-reportable events will continue to be monitored by DDA and/or the MCO during annual quality assurance surveys and/or re-credentialing.

The following procedures will be followed to ensure that reportable incidents for persons supported are tracked, that data is analyzed to determine trends, and the timely reporting of allegations of abuse neglect and exploitation. BRS, Inc. will adhere to all current DDA requirements:

1.	Disciplinary action up to and including termination may be taken against personnel substantiated for abuse, neglect, or exploitation and for reportable staff misconduct.
2.	All reportable incidents are reviewed by the agency Event Management Coordinator (EMC) within 24 hours and turned into DDA within one working day of the incident. The EMC will review the completed reportable incident form (REF) and send to the DDA central office within one working day of the incident occurring. All REFs turned into the DDA central office are reviewed biweekly, but no less than monthly, by the Provider Reportable Event Review Committee (PRERT). Incident action taken is reviewed and recommendations are made for needed actions to prevent future incidents.
3.	The Agency will follow Emergency Precautions Policy 101, Medical Emergencies Policy 102, and Accident/Injury Investigations Policy 103 in Section 8 of BRS, Inc. Policy and Procedure Manual to ensure immediate response to safety and health risks associated with reportable incidents. The above listed policies address:
-	Obtaining medical attention for persons supported and provider staff.
-	Immediate correction of hazards contributing to the incident.
-	Attention to staff conduct that may have contributed to the incident.
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-	Notifying the ISC/CM of incidents.
4.	It is the responsibility of the Agency EMC to ensure the reporting of incidents timely and accurately and to ensure cooperation with DDA investigators and furnishing requested information and documentation promptly upon request.
5.	Falsification of incident reports; making false allegations, providing false or misleading information during an investigation, or the withholding of information during an investigation shall be subject disciplinary including possible termination of employment.
6.	Any person subject to this policy who retaliates against another person for his or her involvement as a reporter, witness, or in any other capacity related to incident management and/or investigations of abuse, neglect or exploitation shall be subject.

Section 2: POLICY 117 – REPORTABLE EVENT MANAGEMENT
Policy:
BRS, Inc. will assure critical incident reporting of people supported in the for 1915c, CHOICES, Katie Beckett and Employment and Community First (ECF) CHOICES
Procedure:
Event management is an important component of an overall approach to ensuring the health, safety, individual freedom, and quality of life of people participating in home and community- based services (HCBS) and ICF/IID services. REM has established provider requirements, forms, and a reportable events database to ensure effective responses to events involving harm or risk of harm to persons supported, as well as preventative measures.
REM has established a clear set of definitions for events that are reportable to DDA (see below), which includes abuse, neglect, and exploitation, as well as behavioral, medical, and other events. BRS, Inc. shall be responsible for performing data collection and analysis for all reportable events and interventions in an effort to identify individual persons supported at significant risk of harm and general provider trends and patterns. BRS, Inc. shall use this information towards reducing individual risk through processes such as Plans of Cares, Support Plans, Circle of Support, etc., as well as reducing general risk through the provider prevention plan process.
BRS, Inc. recognizes those served as having the “Dignity of Choice”. This is understood as the right of a person to make an informed decision to engage in experiences of his or her own choosing, which are necessary for personal growth and development. Supporting dignity of choice means honoring a person’s right to make choices and engage in activities that may involve risk associated with these types of choices and activities, and committing to assist the person to identify, consider, and implement strategies to mitigate the identified potential negative consequences of these choices.

Reportable Event Definitions:

Reportable Medical Treatment - A medical event is reportable if medical treatment occurs during the delivery of services or is discovered during the delivery of services, outside of a diagnosed chronic condition, and requires treatment at an emergency room or urgent care facility. Reportable medical events include conditions such as cellulitis, chocking episodes requiring physical intervention, death, fecal impaction, flu, insect or animal bite requiring treatment by professional, MRSA, pneumonia, pressure ulcer/decubitus ulcer, seizure progressing to status epilepticus, sepsis, serious injury of unknown cause, severe allergic reaction requiring treatment, sever deyhydratio0n requiring treatment, skin infection (other than cellulitis or MRSA), UTI, and other.
Tier 1 Reportable Events: Tier 1 Reportable Events: the alleged wrongful conduct affecting the person by acts or omissions of abuse, neglect, exploitation, or misappropriation of money or property, that resulted in one or more of the following consequences to the person: death, serious injury, or physical harm; physical or sexual abuse; significant pain, intimidation or mental anguish that required medical intervention or loss of funds or property greater than
$1,000 in value. Notice is given to the DDA Investigations (Abuse) Hotline as soon as possible but within 4 hours, and a typed report is submitted by the Event Management Coordinator (EMC) to the  Department of Disability and Aging (DDA) Event Management Unit at Central Office and the MCO within one (1) business day.
Tier 2 Reportable Events: the alleged wrongful conduct affecting the person by acts or omissions of abuse, neglect, exploitation, or misappropriation of money or property, that resulted in one or more of the following consequences to the person: intimidation or mental anguish; probable risk of serious harm; loss of funds or property between $250 and$1,000 in value or prescription-controlled medications regardless of value; or, through supervision neglect harming a citizen in the community or engaging in criminal acts resulting in arrest and confinement. The person did not require medical treatment or an intervention and is not at continued risk of serious harm. Notice is given to the provider EMC and administrator, and a typed report is submitted by the EMC to the DDA Event Management Unit at Central Office and the MCO within one (1) business day.
Reportable Behavioral Event: is an event in which a person presents a challenging action(s) which requires use of a behavior safety intervention or a restrictive behavioral procedure. A REF is required within one (1) business day for an event in which a person presents a challenging action(s) which requires use of a behavior safety intervention or a restrictive behavioral procedure that is not captured as an appropriate response in a plan(s) of care (ex. PCSP, BSP, Behavioral Health Plan of Care, etc.) that pertain(s) to that person. If the use of a behavior safety intervention or a restrictive behavioral procedure is captured as an appropriate response in the person’s plan(s) of care (ex. PCSP, BSP, Behavioral Health Plan of Care, etc.), a consolidated REF will be submitted monthly by the Event Management Coordinator. The Provider Reportable Event Review Team (PRERT) is required to review all Reportable Behavioral Events at least monthly to ensure that the utilization of behavior interventions is appropriate and performed correctly. Reportable Behavioral Events include Reportable Psychiatric Events.

Reportable Psychiatric Event: an event in which a person presents evidence of psychiatric destabilization which requires the use of a psychiatric intervention or crisis services that is not captured as an appropriate response in a plan(s) of care (ex. PCSP, BSP, Behavioral Health Plan of Care, etc.) that pertain(s) to that person.
Other Reportable Events: can include administration of routine psychotropic medication without consent, positive Covid-19 test results, emergency situations (including fires, flooding, serious property damage, that result in harm or risk of harm to service recipient), enabling technology remote supports failure to implement emergency back-up plan, falls with injury, medication variance and omission, missing person for over 1 hour, unsafe environment, vehicle accidents (both minor and serious), or victim of fire.

Section 2: POLICY 118 – COMMUNITY TRANSITION SERVICES
Policy:
BRS, Inc. is committed to providing environments that allow each person the opportunity to grow in a locale that supports the needs of each person served. The Agency also supports the person supported’s need for a safe and positive environment to enhance his/her quality of life in the community.
Circumstances may arise that may require a change in day or residential environments for the benefit of a Person Supported. Any changes in placement will include recommendations from the person receiving services, support team, provider(s), and family/guardian.

Transition Planning will be provided consistent with the requirements per contract and Operations Manual and may be different for Person Supported identified by DDA as “Class Members”. Services may also include Disenrollment.
Procedure:
The Agency, as required, will notify the ISC and/or the DDA Regional Office of the wishes of the Person Supported regarding the requested change.

A Community Transition Plan package will be developed based on information regarding circumstances surrounding the change and alternatives available. The plan will include, as appropriate amendments to the PCSP/Service Plan and all DDA required transition documentation.

Upon approval of the Community Transition Plan by DDA Regional Office, if required, a placement date will be established, and the plan will be implemented.
DDA Regional Office will be provided with information relating to changes in location codes

and/or cost plan changes as required by their guidelines.

Section 2: POLICY 119 – ASSISTING SUPPORTED PERSON SUPPORTED FINANCIALLY ON AWAY VACATION
Any request for staff to accompany and support a person on a vacation must be discussed and documented through the COS. Generally, since this is outside the usual operational boundaries of the agency’s supports, the person can/may pay a portion or all of staff expenses if the COS/person/conservator agrees. This must be added to the PCSP or the PCSP. All the procedures for approval and terms agreed must be well documented. Buffalo River Services, Inc. cannot absorb all costs associated with the act of going on vacation. BRS, Inc. does not expect DSPS to pay for expenses other than what is normal for their usual shift work. There may be exceptions on a case by case basis with any agreements documented in writing. However, it is normal practice to find other sources of funding.
A Person Supported Leave Request form should be completed by managers. There will be specifics for each person’s request. It includes vacation destination, housing accommodations, food needs (eat out/cook in), events (tickets/admissions), travel (agency vehicle/staff vehicle), fuel etc. The circle should discuss what was appropriate for the individual to pay for and the agency would review what they were being asked to cover. If they had a conservator, the conservator would/must give approval.
Our agency pays for 12 hours a day, as staff is allowed to sleep when on vacations. If it's a level 4, two (2) staff must go so that we can bill. We will reimburse meals for staff only at a cap of
$50/day and receipts have to be turned in. It is not cumulative for the trip; it's strictly per day, and we provide the transportation without charge to the person (this means a vehicle and fuel).
The person supported pays for the hotel, house, cabin rental and any attractions that he/she wants to go to and requests for staff to accompany. It must be in the PCSP that it was the person’s choice to go on vacation and requests for staff to accompany them on the trip and any attractions that they wish to enjoy. If the staff wish to help pay for rooms for themselves, this is acceptable but must be put into writing on the form.
The agency may choose to assist in the reimbursement of some of the staffing expenses. Typically, any free funds or charitable donations that can be applied to the expense should be sought after before approaching the agency for financial assistance with the exception of food.
Nothing will be reimbursed without a solid and accurate receipt for each purchase.
In this instance, the individual cannot go without staff, therefore it really is not a “staff/agency” expense. Food, activity, and transportation will typically be covered by the agency with the limit on food expenses at $50.00 per day. Any purchases exceeding that amount is to be covered by the staff person.

The agency can in no way afford to financially assist all of our individuals to go on trips without limits.

Families:
Families should consider giving financial contributions toward supporting expenses for trips such as these. Families should be asked if they are willing to contribute toward the trip.
In most cases the agency should be able to provide a company vehicle to minimize the cost and liability. Staff should contact the places the person(s) want to visit to see if they offer discounts or free passes for non-profits.
In all cases, the agency should not be asked to support expenses of admission, room at hotels, or other expenses. Providers are not reimbursed for trips such as this beyond the usual staffing costs. Therefore, all attempts should be made to find funds elsewhere. The agency cannot afford to send all the people we support on vacation, therefore, in fairness we cannot assume this responsibility for single cases.
As a final note, staff may request assistance from the William Thomas Helton Foundation to pay for some expenses.

Section 2: POLICY 120 – SCHOLARSHIP
Policy:

BRS, Inc. is a not-for-profit, 501c (3), private agency. The Agency receives the majority of funding through an agreement of services with the Tennessee  Department of Disability and Aging. Occasionally, people are in need of services who are not enrolled in the  Department of Disability and Aging, these people should make application for funding as soon as they become eligible. They will then be placed on the state’s waiting list and, by association, on the BRS, Inc. waiting list.

BRS, Inc. reserves two scholarship “slots” for two people who can be served at no additional cost to them or their family provided that they will apply for and be awarded Family Support funding. There will be no more than two scholarship funds at any time. These slots will be filled on a first-come, first-served basis.
Procedure:

The families or the appropriate person/guardian will solicit funding from Wayne County Civitan, and other advocacy organizations. The Agency cannot over-enroll more than two at any time, and that only if the agency has temporary, partial funding of the maximum

allowed from Family Support, as long as Family Support funds are available and the Family Support Council agrees to pay.

As part of the policy, the families of the individuals who are on “scholarship” should be actively engaged in pursuing funding by the Tennessee  Department of Disability and Aging by writing letters and placing telephone calls to the appropriate people. Families will be required to have quarterly Circle of Support meetings with BRS, Inc. to discuss progress being made or lack thereof.

Section 2 Policy 121 – Supported Employment/Vocational Rehabilitation
Documentation is maintained that the services is not available to the individual under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA, b) the services will not duplicate other services provided through ECF CHOICES or Medicaid state plan services, and c) federal financial participation is not claimed for incentive payments, subsidies, or unrelated vocational training expenses disallowed in ECF CHOICES.

Section 3: POLICY 101 - PERSON CENTERED SUPPORT PLAN
Policy:

BRS, Inc. will provide assistance in development as well as interventions and supports based on needs identified in the person-centered Person Centered Support Plan (PCSP) consistent with cost plan and contract requirements. The PCSP will focus on each person’s vision of a desired life recognizing the importance of natural and paid supports. The PCSP will include important information from person-centered planning such as whom the person is, what the person wants from life and what a person may want to learn, how to accomplish desired outcomes, what is important to the person and what is important for the person which includes health and safety. The PCSP will address promoting healthy lifestyles and supporting self-management of chronic illnesses.
Procedure:

Development, maintenance, and accuracy of the PCSP are the responsibility of the Independent Support Coordinator. Care Coordinator, Support Coordinator or DDA Case Manager. The PCSP may be updated as needed but must be updated annually, and will be available to person supported and support providers. When the PCSP is developed, the person’s budget limitations must be considered prior to listing a goal the individual cannot financially support.
Use of one or more person-centered thinking tools can assist in the development of an PCSP. These tools include but are not limited to:

1.	Donut
2.	4 + 1 Questions
3.	Good Day/Bad Day
4.	Important To/Important For
5.	Learning Log
6.	Matching Profile
7.	The Relationship Map
8.	What’s Working/What’s Not Working
Person supported who are in State Wide Home and Community Based Waiver (HCBW) services are assigned an Independent Support Coordinator. Person supported who are Self Determination HCBW services are assigned a DDA case manager who develops and maintains the PCSP.
The Agency documents the implementation of the PCSP, including progress in completing action steps and achieving outcomes. The Agency provides staff training to ensure proper implementation of the PCSP. Staff instructions are used to ensure the completion of PCSP action steps or achievement of PCSP outcomes are carried out.

The Agency completes and documents periodic reviews describing progress related to services provided which are due monthly and are kept in the Agency record. The periodic
review provides a summary of the progress in meeting outcomes. A copy is submitted to the ISC/CM by the twentieth day of the month following the month for which the review was completed. Ongoing evaluation or risk, via the risk assessment process, is incorporated in the periodic review process.

Section 3: POLICY 102 - INDEPENDENT SUPPORT COORDINATION/DDA CASE MANAGEMENT
Policy:
BRS, Inc. provides services by agreement through an autonomous process that consists of Independent Support Coordination organizations or DDA Case Managers. The function of the employees (Independent Support Coordinators/Case Managers) of these organizations is to assist person supported and families in the determination of needs and access to services that meet needs. This process also requires that the support coordination process provide ongoing monitoring, evaluation, and updating of person supported services.

Procedure:
The Independent Support Coordinator. Care Coordinator, Support Coordinator (ISC) or Case Manager (CM) is the person assigned based on geographical issues by his/her employer, and is not an employee of BRS, Inc.
Person supported and/or their families/guardians have the right to request a change in the
ISC/CM by contacting the ISC’s employer or DDA and making a request by phone or in

writing. Contract requirements allow 30 days for the organization to accommodate the change and to provide transitional services. The change may also include a change in the support coordination agency.

Section 3: POLICY 103 - BEHAVIOR SUPPORT PLAN
Policy:

Person supported that present challenging behaviors or require psychotropic medication will be provided with a Behavior Support Plan (BSP). The BSP will be developed with input from the person supported and support providers to enable each person to communicate a want or need in a more acceptable way and to assist in ensuring the safety of support providers and others.

The BSP must be based on person-centered outcomes and contain the results of the following assessments: environmental, quality of life, and functional. The least restrictive alternatives must be used to support the person.
The BSP must be developed for individuals that exhibit three or more instances of behavior in 90 days, and where significant harm to self and others, or damage to property was done or could have been done.
The BSP will only be implemented after the plan is approved by all appropriate committees including the Behavior Support Committee, Human Rights Committee, and support provider(s). Support providers and staff will be trained on the BSP prior to implementation.

The BSP will address a specific behavior. Factors that may contribute to the behavior and the possible modification of these factors will be identified in the Person Centered Support Plan.
Procedure:
Assessment data will be retained as part of the person supported’s record and summarized in the BSP, including type(s) of assessments conducted, date(s) of assessments, and specific results. The following evaluations may be provided:

-	Functional Assessment
-	Functional Analysis as required
-	Quality of Life Assessment
-	Environmental Assessment
-	Person Centered Planning
The minimum information required for the BSP include:
-	Individual's name and address
-	Independent Support Coordinator
-	
-	Supporting agency(ies)
-	Date of Report
-	Author of the Plan
-	Introduction to the person
-	Environmental and lifestyle preferences
-	Relevant medical history and medication dosages
-	Summary of presenting behaviors necessitating the BSP and desired outcomes
-	Summary of all assessments
-	Data related to assessments
-	Preventive procedures
-	Reinforcement procedures
-	Intervention/crisis or emergency management procedures
-	Generalization and management strategies that include staff training methods and situations in which the wanted behaviors will be reinforced
-	Outcomes and quality of life measures
The BSP will be monitored and revised as needed or required by the Behavior Support Committee.

Refer To:
Psychotropic Medication Administration Policy Human Rights Committee Behavior Support Plan and Approval

Note: Psychotropic Medications used for medical treatment do not require a BSP.

Section 3: POLICY 104 - BEHAVIOR SUPPORT PLAN REVIEW AND APPROVAL
Policy:
The author of the Behavior Support Plan (BSP) is responsible for submitting the plan for review following approval by the DDA Behavior Support Committee (BSC).

Procedure:
Sufficient copies will be provided for the BSC Chair or designee to distribute to all members of the Human Rights Committee prior to the meeting.

A review of the BSP will include information to ensure that informed consent has obtained, the BSC has approved the plan, and psychotropic medication policy will be followed.
The Human Rights Committee may approve, conditionally approve, or disapprove the BSP by a majority vote. HRC approval is only required if the BSP contains restrictive intervention. If the BSP is inclusive of restrictive behaviors & rights restriction or the BSC may request HRC review of a plan involving a particularly complex situation.
The approved BSP will contain the approval form signed by the Chair. The Human Rights

Committee must specify the frequency of review and monitoring as well as the duration of the approval. Approval may not exceed 12 months.

Section 3: POLICY 105 - INDIVIDUAL CRISIS PLAN
Policy:
Person supported that exhibit-challenging behaviors may require crisis intervention consistent with contract guidelines. A crisis plan may be implemented when a person supported by the Agency is seen as being in imminent danger of hurting himself or others, or when the staff supporting the person determine they do not know how to support the person in the planned or typical manner.

In an effort to promote services that provide physical, emotional, and psychological wellbeing, prevention and early intervention will be a priority of the Agency when challenging behaviors are present.

Person supported that have been identified as vulnerable to crisis will be evaluated to determine the most effective strategies and interventions. An individual crisis plan will be developed that will identify:

-	Initial response and assessment that include actions to protect everyone involved in the situation. This generally involves getting out of the way of any possible violent or confrontational situations.
-	De-escalation strategies will be used after removing oneself from immediate harm.
-	Strategies such as redirection and distraction may help reduce the aggressive situation to one that is manageable and safe.
-	Backup support will be provided, and staff will know whom to contact and in what order to do so. A notification protocol will include immediate supervisor, agency management, behavior analyst support, and other trained staff.

Procedure:
Staff and support personnel will be trained in Agency crisis management as well as behavioral crisis management consistent with the Department of Intellectual and Development Disabilities requirements. The training will include:

-	Identifying a developing crisis and interventions strategies
-	Ways to redirect a crisis
-	Ways to protect the safety of all persons involved
-	Guidelines on how and when to use emergency services
-	Use of emergency restraint

Person supported identified as vulnerable to crisis will have an Individual Crisis Plan located on-site that will include information on identification of crisis and notification information.

The Individual Crisis Plan will be implemented as part of the General Crisis Plan and consistent with policy. Notification as follows:
-	Immediate supervisor
-	Agency management
-	Behavior Support Analyst
-	Independent Support Agency/Coordinator or Case Manager
Events that require the implementation of the Individual Crisis Plan will be considered a serious incident and reported consistent with guidelines established in the Protection from Harm Policy.

Conditional approval of the BSP will reflect the need for changes and further review by the Human Rights Committee prior to approval and implementation.

Disapproval recommendations may be appealed by the author of the plan.

Emergency approval may be provided in cases approved by the BMC and submitted to the Human Rights Committee Chair for temporary approval not to exceed 30 days. The BSP may be implemented if the Human Rights Committee Chair concurs that the person supported will be placed at risk of harm if the BSP is not implemented prior to the next meeting.

Section 3: POLICY 106 – SERVICES IMPLEMENTATION

In order to effectively execute each individual’s Person-Centered Support Plan (PCSP), Buffalo River Services develops and executes an implementation strategy to provide detailed instructions for program managers and direct support professionals on how to best support each person they serve, who receives Employment and Community First (ECF), DDA or Choices waivered supports. An Initial Implementation and a Final/Complete Implementation will be created.
Process:
1.	Once the determination is made that Buffalo River Services will support a person on the ECF waiver, the assigned Buffalo River Services Centered Trainer/Facilitator will work with the assigned Area Director to schedule the initial Buffalo River Services Person-Centered planning meeting to develop a preliminary Person-Centered Description and PCSP, including initial outcomes. When possible, this should occur at least 30 days prior to transition.
2.	The Initial Implementation Support Plan (IPCSP) will be submitted to Buffalo River Services Area Director (AD) for review and approval. Approval must be provided within 5 business days of service initiation.
3.	AD submits approved Initial Implementation Support Plan to the Buffalo River Services QA and Compliance Coordinator and to the person’s Managed Care Organization (MCO) within 3 business days of approval.
1.	
4.	Standard and compliance coordinator will enter the Initial Implementation Support Plan into TIMAS as PCSP Outcomes and upload both the PCSP and the Initial Implementation Support Plan into the TIMAS account.
5.	Within 60 days, the person supported and the Buffalo River Services support team will participate in the development of a full Person Centered Description and Final Completed PCSP with support outcomes that:
A.	Are reflective of the person’s lifestyle, goals, and outcomes
B.	Include schedule, locations, and activities
C.	Short term and long-term objectives, goals, and outcomes
D.	Teaching and support methods
E.	How and what interval progress will be measured
F.	Risk mitigation strategies
G.	DSPs and back-up who will deliver the service
H.	Fading plans
6.	Completed Implementation Support Plan (PCSP) will be submitted to Buffalo River Services Director (AD) for review and approval. Approval must be provided within 5 business days of receipt.
7.	AD submits approved Implementation Support Plan to the Buffalo River Services management the COS and to the person’s Managed Care Organization (MCO) following the DDA guidance for services located in the Quality Monitoring tool.
8.	Standards and compliance coordinator will enter Implementation Support Plan into TIMAS as PCSP Outcomes.
9.	Prior to service initiation, and then again after complete PCD/PCSP, assigned Buffalo River Services Manager (PLPM) holds Needs-Specific Training meeting with the person supported and the DSP’s who will provide supports. Meeting may be held in person, by phone, or by video conference. Training for DSPs will be documented in TIMAS.
10.	As new DSPs are introduced into the person’s program, prior to them working a shift.
11.	TIMAS is used to document work on PCSP outcomes.
12.	Amended Implementation Support Plan (PCSP) will be submitted to Buffalo River Services Area Director (AD) for review and approval.
An Area Director can be the Chief of Innovation for MAPS and Technology, County Administrator,
Program Director or County Director depending on the person’s needs.

Section 4: POLICY 101 - MEDICATION ADMINISTRATION BY UNLICENSED PERSONNEL POLICIES AND PROCEDURES
Ref: ECF Quality Monitoring indicator 7.c.4 Updated 12/22

PURPOSE

The purpose of these policies and procedures is to provide overall instruction for the management of safe medication administration by unlicensed personnel.

I.	MEDICATION PROHIBITIONS
A.	The use of medication for chemical restraint by staff is prohibited.
B.	Medication will not be used as punishment.
C.	Medication will not be used for the convenience of staff or as a substitute for training.
D.	No medication will be administered for the purpose of controlling or modifying behavior except as provided for in the rules of DDA and the health care plan.

E.	Administration of medications to a person under the age of 18 is not covered under the exemption rules.

II.	SELF-ADMINISTRATION
The Division of Intellectual and Developmental Services defines self-administration as follows:
“Personally using prescription medication in a manner directed by the prescribing practitioner without assistance or direction by program or facility staff, in accordance with DDA standards.” (A verbal reminder that the time of taking a dose of medication has arrived does not constitute assistance or direction by program staff.)
Whenever possible, individuals should be taught and/or encouraged to administer their prescribed medications as independently as possible.
A.	Each Self-Administration Program should be developed according to the person’s needs and capabilities, e.g., there is no generic program that is applicable to all persons.
B.	The circle of support and treating practitioner will evaluate the person’s functional
and cognitive ability to self-administer, as appropriate.
C.	Self-administration training must be done in conjunction with the person’s circle of
support and treating practitioner.
D.	The program must be included in the person’s Person Centered Support Plan (PCSP).
E.	A program consultant may be engaged to provide direction and leadership with program development.
F.	See Medication Storage and Labeling for guidelines related to self-administration.
A.	
G.	The use of technology such as an automatic medication dPCSPensing machines, will be engaged after approval of the Circle of Support. Each person will have a plan developed for risk management, safety and instructions for agency personnel in the use of the devices. Training will be obtained from the vendor. Only the medication pharmacy will load the medication. Staff will monitor for changes and follow up as needed.

III.	STAFF REQUIREMENTS
A.	Unlicensed staff may administer medication to people who do not self-administer only if he/she has passed the Department Intellectual and Developmental Disabilities Services (DDA) approved Medication Administration by Unlicensed Personnel Training Program and has a current certification issued by the DDA. A certificate awarded upon completion of a training program is a traditional method for denoting those people who have successfully completed all requirements of the program. Initial certification is awarded after successful completion of the twenty
(20) hour course. Every 3 years the course will be repeated or the staff person will “test-out”. The agency has a system to ensure that staff receive and maintain current certification or license to pass medication.
B.	Staff must provide a copy of his/her certification to the Program Director or designee, which will be maintained in the employee records for training.

C.	Certified staff will administer medication as assigned by the Program Director or designee.

D.	The agency may submit recommendations based on evidence for termination of a
staff person’s certification and authority to administer medication.

IV.	PROGRAM REQUIREMENTS
A.	The Agency Trainer or designee will maintain a registry of certified staff. The registry will also include the date for recertification for each staff. Staff and/or their team leader will be notified of date for scheduled recertification.
B.	The Program Director or designee will immediately notify the DDA Regional Nursing Director in writing when a certified employee has approval to administer medication withdrawn by the agency.
C.	The Program Director or designee will authorize, by shift and days, who among certified staff will be responsible for medication administration.
D.	The Team Leader or their designee will immediately notify the Case Manager or designee of any:
1)	Suspected shortages or diversion of prescription medications.
1)	
2)	Suspected misuse of prescription medication. This includes sharing medication, e.g., using or giving medication prescribed for
a specific person to another person (even if the other person has the same medication prescribed).
3)	Violation of medication regulations (progressive disciplinary actions and retraining will be used as required by agency policy).
4)	Administration of medication in a way that is inconsistent with the treating
practitioner’s orders and is believed to cause risk of harm to a person.
5)	Administration of a medication for which the person has had a documented allergic reaction, sensitivity, food/drug interaction and/or a contraindication.
6)	
Only licensed personnel are permitted to transcribe a verbal order from a treating practitioner. When this occurs, the practitioner signature will be obtained in less than 5 working days.

E.	The Program Director or designee will promptly notify the DDA Regional Nursing Director of any of the above occurrences.

V.	DOCUMENTATION ON THE MEDICATION ADMINISTRATION RECORD (MAR)
A.	All medications, whether prescription or over-the-counter (OTC), must be treated as follows:
1)	All medication orders must be written on a Physician Order Sheet, Prescription Form or an approved electronic form and signed by the treating practitioner.
Each order must specify the following:
a)	Date ordered, including year;
b)	Name of the person for whom the medication is ordered;
c)	Name of the medication/drug;
d)	Dosage;
e)	Route of administration, e.g., oral, rectal, vaginal, Ophthalmic, etc.;
f)	Frequency and duration of administration;
g)	Pre-test orders must specify the period of time of pre-test administration, e.g., one hour before EEG; and
h)	Treating practitioner’s signature.

2)	All medication orders must be noted on the Medication Administration Record (MAR).
a)	Name of the medication/drug, rational/reason for taking.
b)	Dosage and strength, if applicable.
a)	
•	Some medications have different dosages ordered for different time intervals. A separate entry on the MAR must be made for each medication dosage prescribed e.g., Depakote 500 mg every a.m. and Depakote 100 mg every p.m.

•	Some medications are only made in certain strength. In order to give the prescribed dosage more than one tablet must be given to equal the prescribed dosage. For example, the treating practitioner orders Tylenol 650 mg, each Tylenol tablet contains 325 mg. Therefore, to give the prescribed dosage, two (2) Tylenol tablets must be given to equal the required dosage.
EXAMPLE:
Tylenol	325 mg (1) tablet = strength
+325 mg (1) tablet = strength
650 mg (2) tablet – dosage

c)	Route of administration, e.g., oral, rectal, ophthalmic, etc.
d)	Time the medication is to be administered.
Medication should be administered no earlier than ½ hour before the stated time and no later than ½ hour after the stated time.

e)	If the medication is ordered for a set number of days, the start and stop date must be noted.
f)	Any high-risk medications or special considerations for administration must be listed, e.g., give ½ hour before meals (a.c.), give ½ hour after meals (p.c.), give with food, give with 8 oz of water, special positioning, swallowing techniques, texture consistency, medications which may or may not be crushed, medications requiring close monitoring, etc.
g)	Medications ordered on an “as needed” (p.r.n./P.R.N.) basis may be administered by certified staff only when the parameters for its use are clearly identified by the order, e.g., Tylenol 650 mg by mouth every 4 hours PRN for temperature greater than 100 degrees orally. If temperature persists for more than 48 hours, notify physician.

h)	Certified staff will not administer PRN medication when:

1.	Assessment by a licensed nurse is indicated.
2.	The parameters for administration are not clearly identified, e.g., PRN for rash.
3.	Administration of that medication as ordered does not comply with DDA regulations.
1.	
4.	Certified, unlicensed staff will never administer psychotropic medication on a PRN basis.

B.	The MARs must be kept in a separate notebook.
1)	Medication orders recorded on the MAR must be transcribed exactly as written on the Physician Order Sheet and the current prescription label on the medication container. A copy of the medication order will be maintained in the notebook with the current MAR.
2)	A copy of the Medication Profile Sheet containing side effects, precautions, and other pertinent information related to the medication being administered must be filed in this notebook and located in a place readily accessible to the staff administering medication.
C.	Certified staff designated to administer medication, including ordered over the counter (OTC) medications and treatments will be responsible for documenting on the MAR the following:
1)	Date and time the medication is administered;
2)	Reason for individual’s absence from facility/home (hospital, trip, home with family, etc.) Any out-of-home administration of medication which occurs during the time that the certified staff is assigned to medication administration;
3)	Any inconsistencies in administration of medication as ordered by the treating practitioner; and
4)	Their initials and legal signature on the MAR.

Note: MARs and medication count sheets are legal documents and must be completed in black ink. No highlighting should be done on MARS, except to highlight (with a yellow highlighter) a DC’d (discontinued) order. No marker or sharpies should be used on MAR on Count sheet.

D.	Blank spaces are not acceptable.
1)	If an ordered medication is not given for any reason, the medication block must be initialed and circled, and the reason why it was not given recorded on the back of the MAR. Examples include:
a)	Refused
b)	Withheld
b)	Not available
c)	Omitted Given in another form
d)	Given by another route, e.g. rectal, oral
e)	Given in another strength, e.g. Tylenol 500 mg instead of 325 mg

1)	If it is determined that a scheduled medication was given in an
1)	
alternate form, by an alternate route, or in an alternate strength than ordered, a Medication Variance Form will be completed and the prescribing practitioner notified.
If a staff discovers a blank block on the MAR where a medication administration was scheduled, that staff will complete a Medication Error/Omission Form. A line will be drawn in the box.
2)	Draw a line in the block indicating days medication is not to be administered, e.g., medication is ordered for every other day, days meds are given at day service on home MAR and vice versa.

3)		The documentation of medication administration given out-of- home should be documented using the codes listed on the MAR.
4)	When a medication is missed or initials are missed, circle the block and go to the back of the MAR and write the reason why.

NOTE:
Þ	Any time one of these codes is used on the MAR, there must be an explanation of the use of that code on the back of the MAR.

E.	If a person receives medication at two or more different sites, the documentation for administration will be done at both sites. For example, if a person receives medication at both a day and residential site, the MAR must be maintained at both sites. The current MAR will be located in the individual’s travel notebook for a one- month period. After that time, it will be filed in the individual’s record. A copy of the Physician Order Sheet and copies of the Medication Profile Sheets will be made available at the beginning of each month and immediately when medication orders are changed by the treating practitioner.

F.	Any change in a treating practitioner’s medication order will be considered a new
order and must be documented as such on the MAR.
G.	Any time there is a change in medication orders, e.g., allergies, new drug, dose change, time change, etc., this change must be communicated to other staff as follows:

1)	Verbally reporting the change in orders;
2)	Documenting the change in orders in the Communication Book or via agency email;
3)	Any medication changes require medication to be sent back to the pharmacy for repackaging and placing a newer label over the old one is not allowed; and
1)	
4)	When the dosage of medication is changed, any previous dosage must be discontinued before starting a new dosage.
H.	When new medications are received from the contracting pharmacy, the MARs are sent by the pharmacy matching the orders. If a outsourced pharmacy is used and MARS are to be completed by the agency certified staff, they are reviewed by the staff for accuracy and amount. The date, medication, dosage, and amount received should be documented on the back of the MAR. Home staff will complete cross referencing checks by different people including the Lead LPN on receiving the medications on the new month's MARs prior to being put into use.
I.	Medicine Audit (counts) will be performed on all meds at a minimum of weekly at each site.
J.	If med audit shows medication supply is low (less than 5 days-worth on hand), it is the responsibility of the person performing the medication audit to notify the pharmacy a refill is needed.
K.	All staff who administer medication is responsible for ensuring that an acceptable amount of medication (minimum of 3 days) is available.
L.	Guidelines for Administering Medications (per Medication Administration for Unlicensed Personnel Training Manual):

1)	Give medicines only upon written orders from the PCP.

2)	The person administering the medications has the responsibility to know the medication’s intended use, the purpose for which it is being given, any unfavorable reactions or side effects which might occur, any warnings or distractions of a specific nature concerning the medication, and the usual dose.
3)	It is the responsibility of the person administering medications to be familiar with the condition of the person (e.g., allergies to certain medications, ability to swallow).

4)	The following items are important responsibilities of the nurse or the unlicensed personnel. They must see that the medications are prepared and delivered according to the “Eight Rights”:
a.	The Right
i.	PERSON
ii.	MEDICATION
iii.	DOSE
iv.	ROUTE
v.	TIME
vi.	POSITION
vii.	MEDIUM/TEXTURE/CONSISTENCY
viii.	DOCUMENTATION
i.	
5)	Medications must be identifiable up to the point of administration.
6)	Avoid distractions.
7)	The person receiving the medication should be told about the purpose of the medication and expected effects.
8)	Each MAR must be read carefully. If not clear, refer to the PCP order sheet/prescription label or check with a pharmacist or the PCP. The information (e.g., person’s name, name of medication, route of administration, dosage, time ordered) must be the same as the PCP order.
9)	Read the label of the medication container carefully, checking to see that the label and the MAR read exactly the same. The label on the medication container should be read three times as follows:
a.	When the container is taken from the person’s supply;
b.	When the medication is removed from the container; and
c.	When the container is returned to the person’s supply.
10)	Never take medication from an unmarked or soiled container, or a label that is readable.
11)	Keep all containers tightly closed to prevent any changes to the medication from occurring. Any change in color, consistency, or odor of medication must be reported to the designated supervisor, pharmacist or PCP.
12)	When administering medication to a person, verify that it is the correct person.
Photographs on the person’s MAR may be helpful.
13)	Give the medication at the time it is ordered and remain with the person until the medication is taken.
14)	Provide privacy to the person during medication administration when it is indicated (e.g., rectal medications).
15)	Medications that have been prepared and not given to the person for any reason (refusal, absence, etc.) are to be discarded. Never return medications to their container.
16)	The unlicensed person must be aware of the additional responsibilities concerned with their administration of controlled substances according to the agency policies and procedures.
17)	If the person refuses the medication, three (3) attempts should be made, within the designated time frame before it is recorded as refused. Refused medication must be reported to the designation supervisor and the PCP. Refused medication must be recorded on the MAR.
18)	When administering medication, the principle aspect of universal precautions must be followed.
19)	Medications must be given at the prescribed time. The window of time is one- half hour before or on-half hour after the prescribed time.

M.	Agency must assure each unlicensed employee is routinely monitored (see also agency Plan of Supervision). First medication pass after certification is monitored. The Program Director and assigned staff will do random, unannounced monitoring of unlicensed staff during medication administration to ensure that it is done correctly
A.	
according to the requirements. During that time the MAR will be checked to ensure
that all doctor’s orders and side effects sheets are with the MAR and are up to date.

VI.	EDITING MEDICATION ADMINISTRATION RECORDS (MARs)
A.	MARs will be edited monthly for allergies, completeness and accuracy to ensure that all the medication orders correlate with the current signed Physician Order Sheets. Manually prepared medication records must also be compared to the current signed prescribing practitioner’s orders.
B.	The second check will be done on the last day of the month. Staff must date and initial on the back of the MAR to show the check has been done.
C.	Any discrepancy in the medication records must be clarified by the pharmacist or treating practitioner, if necessary.
Discrepancies may be discovered and brought to the attention of the pharmacist or prescribing practitioner by:
DSP’s LPN’s
Team Leaders Managers
D.		A final check by certified staff is done prior to medication administration on the first day of the month. This is done to ensure that any new orders written since the day the medication records were edited and the first day
of the month are transcribed completely and correctly onto the new MAR. Staff must date and initial on the back of the MAR to show check has been done.

VII.	DOCUMENTATION OF CONTROLLED SUBSTANCES
A.	All Schedule II-VII medications, (e.g., narcotics, tranquilizers, and barbiturates), should be marked as such by the pharmacy to ensure that certified staff know to record them in the Controlled Substances Book. In addition, staff should refer to Appendix 5 for Schedule of Controlled Substances.
B.	All Schedule II-VII medications (e.g., narcotics, tranquilizers, and barbiturates) stored at the house must be documented in the Controlled Substances Book and counted/reconciled at the end of every shift/time period.

C.	The count must be done in the presence of two (2) staff, e.g., one staff from the off-going shift/time period and one staff from the oncoming shift/time period, both of whom must be certified to administer medication.
A.	
1)	At those times when off-going and oncoming staff do not come in contact with one another, the off-going staff will reconcile the drug count at the conclusion of his/her shift/time period, preferably with another certified staff as the witness, if available.
2)	The oncoming staff will then do the drug count at the beginning of the shift/time period, preferably with another certified staff as the witness, if available.

3)	If a witness is not available, the staff will write “not available” on the
appropriate line adjacent to his/her signature on the count sheet.

4)	The off-going staff member may not leave the job site until the count is reconciled.

D.	The oncoming certified staff must count the Schedule II-VII medications, confirm the given doses, and verify that the count and documentation are correct by signing the count sheet.
E.	The Controlled Substance Usage Log will help with the MAR and/or with the medication.

When a controlled substance is discontinued or expired, the amount sent for dPCSPosal must be noted on the Controlled Substance Usage Log and initialed by 2 staff. The Controlled Substance Usage Log must go with the medication along with the Medication DPCSPosal form. Discrepancies in the drug count or suspected theft must be reported immediately to the Program Director or designee. After office hours On-Call must be called. In addition, any drug loss or excess must also be reported. The Program Director or designee must report these discrepancies to the DDA Regional Office within 24 hours (or in the event of weekends and holidays report the next working day.)

VIII.	MEDICATION REFUSAL
A.	If a person refuses any form of medication, every effort must be made to determine the basis for the refusal.
B.	Several attempts, at least three (3), should be made within ½ hour before or after the stated time of administration before documenting this as a refusal.
C.	After several unsuccessful attempts to give the medication, the Technical Assistance/Emergency Protocol must be initiated. This must include notification to the physician and the conservator/guardian.
D.	If the refusal of medications continues, the person’s circle of support or behavior
support should be notified.

E.	At no time will the missed dose be “made up” at the next scheduled medication
dosage time.

IX.	LEAVES OF ABSENCE (LOA)
There may be occasions when medication (both prescription and over the counter (OTC) will be administered by a parent, family member, guardian, or other individuals having a close relationship with the person. Most typically, the situations will occur when the person is on vacation or visiting with that individual.

A.	Medications administered while the person is on LOA must be documented on the MAR using the appropriate documentation key, e.g., V = Visit/Vacation.

B.	The certified staff will obtain from the pharmacy an accurate and clearly labeled supply of medication to last the proposed time during which the person will be with the identified individual(s).
D.	The certified staff will provide the person administering the medication with verbal and written instructions for the administration of the medication, a copy of the Medication Profile Sheet, and inform them to call if there are any questions or concerns. Included in the list of instructions are:

1)	Who to call for technical assistance or in case of an emergency along with their telephone numbers.
2)	Preparation of medication or special instructions for administration.
3)	Special circumstances, if any, for omitting the medication.
Upon return to the house, the person administering the medication will return the medication, if any, that were not given. If there are any returned medications, staff will fill out Med error/omission form, document missed doses on the MAR, and dPCSPose of missed medication per the medication dPCSPosal policy. There may be exceptions for medications that are issued in a dated dial pack, such as Birth Control Pills. In these situations, the pharmacy and/or treating practitioner should be contacted for special instructions.

X.	MEDICATION ERRORS/OMISSIONS REPORTING, MANAGEMENT, AND TRACKING
Medication errors/omissions will be reported, managed, and tracked consistent with the DDA rules and regulations. In addition, when medication errors/omissions are considered serious and/or have the potential for abuse/neglect, an accompanying Reportable Incident form must be completed (refer to the DDA Medication Variance Report). The DDA approved medication variance report must be completed upon discovery.
A.	Medication Variances.
1)	The following medication errors/omissions must be reported immediately to
1)	
determine the appropriate action:
a)	Wrong person receives medication;
b)	Wrong medication administered (or person receives medication to which there is a documented history of allergy/sensitivity, or a person receives medication for which there is no order);
c)	Wrong dose;
d)	Wrong time;
e)	Wrong route;
f)	Missed/omitted dose;
g)	Incorrect transcription of medication order;
h)	Documentation errors, e.g., administering medication but failing to initial the block on the MAR; not documenting on the Controlled Substances Count Sheet, not documenting PRN medications and results of medications given, etc.;
i)	Administering medications prescribed to treat behaviors without obtaining consent from the guardian/conservator;
j)	Finding medication in an inappropriate area, e.g., in person’s clothing, on the floor, packaged with a meal, in an unlocked container, in an unmarked open container/dish, or mixed together in an open container, etc.;
k)	Not ensuring an adequate supply of medication available or that new prescriptions are not obtained within a reasonable time;
l)	Security/storage protocols not followed; and
m)	Any other medication errors/omissions that involve medication administrative not previously listed.

NOTE: When a situation is considered to be urgent, emergency measures must be undertaken without delay, with notifications to follow.

B.	Documenting Medication Variances
1)	The medication error/omission form must be completed immediately by the staff discovering the medication error/omission. This form must be turned in to the office no later than the next business day.
2)	The agency RN or designee will ensure that a DDA medication Variance report form is completed and maintain files of the completed forms for review by DDA nursing department.
3)	The agency will identify, track, and trend errors and provide an accounting of their reports to the Regional Nursing Department. The medication variance report will be completed by the agency RN or designee. Trends will be submitted on a monthly basis & report sent via email by the 10th of the following month.
4)	In the event that non-certified who were never certified or expired administer medications it will be reported to DDA in the appropriate reporting format.

The forms will be sent as indicated by the Provider Manual.

C.	CORRECTIVE ACTION
1)		Progressive disciplinary action will be taken with each staff as errors occur. Each error will be filed in the staff member’s personnel record. The disciplinary process for medication errors/omissions/non-signatures will cover a 6-month span of time from the first date of disciplinary. After 6 months, unless a staff has reached the probationary period of this process, the process will be started fresh and the past 6 months disciplinary not counted. If a staff has reached the probationary period of the disciplinary process, it must continue and their disciplinary process will not start over until the full probationary period is completed successfully. The progressive disciplinary process is as follows:

1st offense: Staff receives verbal warning from the Team Leader/Program Director/Coordinator which is recorded in their personnel file
2nd offense: Staff receives written warning from Team Leader/Program Director/Coordinator and counsel with agency RN.
3rd offense: Staff receives last written warning and counsel from Program Director.
4th offense: Staff’s medication certification is revoked, must retake training, and
placed on 90 days probation.
Last offense: Staff’s employment may be terminated. (if error within 90 days
probation).
2)	In situations where a specific work location has unidentified errors (the person/persons responsible for the errors cannot be identified) or numerous identified errors, that team will be placed on Code Red Status. (see Code Read Status Policy).

XI.	TECHNICAL ASSISTANCE/EMERGENCY PROTOCOL
A.	Persons receiving medication may experience side effects or adverse reactions to their medication resulting in emergency, urgent, or non-emergency situations. In the event such situations occur the measures listed below should be followed:

1.	Emergency conditions that are life-threatening, such as extreme difficulty in breathing or absence of breathing, absence of pulse, a seizure that will not stop, severe injury or profuse bleeding, etc. require immediate activation of the Emergency Medical System (911 or other emergency numbers including the Poison Control number). These numbers must be located on or near the telephone.
1.	
2.	Urgent conditions which are potentially life-threatening must be evaluated by the treating practitioner, consulting physician, or emergency room at once. When a condition is considered urgent and the treating physician cannot be contacted, there must be no delay in the evaluation or treatment of the person. Immediately contact or proceed to the emergency room.

3.	Non-emergency conditions that are potentially health-threatening such as mild diarrhea, nausea, occasional vomiting, or any physical or behavioral signs and symptoms which may indicate that the health or safety of the person is at risk, must be reported as soon as possible. Staff must report their findings to the Case Manager, Team Leader, Program Director, Agency Health Consultant or designee and seek advice and assistance.

a.	If unable to contact these people, advice and assistance can be obtained from the person’s treating practitioner or consulting physician, as appropriate. The on-call management staff will always be notified.

b.	If none of these individuals is available, the outpatient clinic or emergency room should be utilized.

4.	Names, telephone and/or beeper numbers (including after-hours numbers) of treating practitioners, consulting physicians, administrators, staff and/or other individuals that may need to be contacted must be available in a designated area for staff to access as needed.

5.	The staff recognizing an emergency/urgent condition is/are responsible for ensuring that it is properly reported, documented in the person’s record, and that a DDA Reportable Incident form is completed.

B.	If there is a non-urgent question about a medication, its administration, or side effects and an agency licensed nurse is not available, staff should contact the pharmacist, treating practitioner, or the emergency room for help, in that order. Also, the on-call management staff will be notified.

C.	A published drug reference will be kept in a designated area in the residential home and will address for each medication the following information:

•	Any contraindications, food/drug interactions, and/or possible allergic reactions/sensitivities.
•	
•	Special precautions, common risks, side effects/adverse reactions, and contraindications of the drug.
•	Conditions (or illnesses) for which the drug is commonly prescribed.
•	Special considerations that should be noted, e.g., give with water; encourage fluid intake; give with food; etc.

D.	Medication Profile Sheets for each individual’s current medications are maintained in the person’s travel book with their current MAR.

E.	Issues involving the interpretation of the Medication Administration Regulations should be referred to the appropriate DDA Regional Nurse.

XII.	MEDICATION DPCSPOSAL
Medication will be dPCSPosed of when the following occurs. DPCSPosal for single doses will occur in a manner consistent with FDA guidance. A Chain of custody up to actual destruction will be documented.

A.	Medication must be destroyed when it is:
1)	Contaminated, e.g., dropped on the floor, “spit” out by person, unusual
color, a capsule leaking on another medication, etc.;
2)	Refused;
3)	Discontinued;
4)	Expired;
5)	Labels missing or labels that are so illegible the name of the person to whom it belongs and/or the name of the medication or prescription number cannot be read.

B.	To dPCSPose of medication, two (2) certified/licensed staff will count the medication being dPCSPosed of. A Medication DPCSPosal Form will be completed and signed by both staff. The medication, along with the completed Medication DPCSPosal Form will be turned in to the Program Assistant.

C.	The Program Assistant will verify the count and sign the Medication DPCSPosal Form. The meds, along with the Medication DPCSPosal Form will be taken to the pharmacy for dPCSPosal. The Program Assistant is responsible for obtaining the completed and signed Medication DPCSPosal Form from the pharmacy. Medication should be taken to the pharmacy at least monthly. Controlled substances should be taken to the pharmacy no later than the next business day after they are received by the office.

D.	To dPCSPose of Controlled Substance, it must be documented as follows:
A.	
Þ	For Schedule II - VII medication (e.g., narcotics, barbiturates, tranquilizers) the two certified staff that are responsible for removing a medication from the Controlled Substance Usage Log must date and sign the page. Deduct amount destroyed from the count page. Note that medication was dPCSPosed of according to the agency policy. Complete the Medication dPCSPosal form. The Controlled Substance Usage Log must accompany the medication and the Medication DPCSPosal Form to the office of the Program Assistant.

E.	When medication is destroyed, the DPCSPosal Record must include the following information:

1)	Date and time;
2)	Name of the person for whom the medication was prescribed;
3)	Name, strength and form of the medication (e.g., 125 milligram tablets of Depakote, 10 cc Tylenol liquid, etc.);
4)	Amount destroyed giving exact quantity of drug. (e.g., number of tablets, capsules, amount of liquid, etc.);
5)	Reason;
6)	Means of destruction, per agency policy. If only one dose of medication is to be dPCSPosed of (e.g., dropped on the floor, found on the floor, etc.) two certified/licensed staff should flush the medication down the toilet as a last resort. It is preferred to use coffee grounds, kitty litter or other granular medium or material designed for dPCSPosal and to crush pills or pour liquid into medium then put in trash. Medication should be rendered irretrievable. Always complete the Medication DPCSPosal Form indicating medication was flushed, then the form must be turned into the Program Assistant; and
7)	Signatures of certified staff destroying/witnessing.

F.	Copies of the DPCSPosal Records are kept on file at the agency.

XIII.	MEDICATION STORAGE AND LABELING
A.	Prescription and OTC medications for all persons, including those who are self- administering, must be labeled and stored in a locked container or area which is designated strictly for medication storage, supplies, and records relevant to medication administration.
B.	Medications for persons who are self-administering must be stored in such a way as to make them inaccessible to all other persons. Such medications must be stored in a locked container or area.

C.	In cases where an automated medication dPCSPenser is used, it must be prior approved by the person’s Circle of Support and added to the Person Centered Support Plan. An automated medication dPCSPenser must be monitored, refilled and maintenance by a qualified pharmacy.
A.	
D.	Only certified staff assigned to medication administration for the shift will have access to the storage areas.

E.	Prescription medication must be stored under each person’s name, e.g., in hanging
folders, plastic bags, or in bins.
F.	External and internal medications must be stored separately, e.g., different shelf, drawer, or plastic bag.

G.	All Schedule II - VII medications (e.g., narcotics, barbiturates, and tranquilizers) must be kept double locked, e.g., a locked cabinet behind a locked door; a locked box within a locked cabinet.

H.	Medication requiring refrigeration must be stored in a locked container within the house refrigerator, or in a separate locked refrigerator.

I.	If a person receives medication at two or more different sites, a prescription must be obtained from the pharmacy for use at each site; or the medication may be transported in a locked container from one site to the other.

J.	Medication labels that do not reflect the current treating practitioner’s order due to a recent change in the order must be returned to the pharmacy for repackaging/relabeling.

K.	Any medication containers with illegible labels, (e.g., cannot read the person’s name or the name of the medication, worn, or missing labels) must be returned to the pharmacy for repackaging/relabeling or dPCSPosed of per agency policy and a replacement obtained from the pharmacy.
L.	All medications should be counted upon receipt from pharmacy. If amount is incorrect, notify pharmacy immediately.

M.	Staff are responsible for maintaining a 3-day supply of medication/supplies at all times.

XIV.	SECURITY
A.	It is the Program Director’s or designee’s responsibility to designate certified staff to
administer and secure medications.
B.	The certified staff assigned to administer medications will be responsible for the medication keys and will be the only person to have access to the medication storage area during that shift. The key must remain with the assigned staff at all times.
A.	
C.	Combination locks are not acceptable.

D.	If the medication key is lost or mPCSPlaced, the Program Director or designee must be notified immediately.

E.	The Program Director or designee will have an extra key kept in a separate (locked) location in case the original medication key is lost or mPCSPlaced. Knowledge of the location of the extra key must be restricted.
F.	Medications are to be under lock when transported by the agency.

Section 4: POLICY 102 - MEDICATION ADMINISTRATION CODE RED STATUS POLICY

What is “Code Red” status?
Code Red is the status in which work locations are placed under when unidentified med errors or numerous identified med errors have been occurring within the location at high frequencies. The purpose of the Code Red status is to increase oversight of medication administration within the location, to help identify the causes of unidentified med errors (i.e. persons making the errors), and to reduce the amount of med errors from occurring.
What are “identified” and “unidentified” med errors?
Identified med errors are errors in which the person responsible for making the error can be identified based on the MAR, med counts, or by admission. Unidentified med errors are errors that have occurred in which no single staff member can be identified as the person responsible making the error.
How is a location placed under Code Red status?
In the event that 3 or more unidentified med errors occur within a single location (residential/SL home, PA site or day service program) within a calendar month, that location will be immediately placed on Code Red status. In the event that numerous unidentified med errors or blatantly negligent handling of medication administration occurs within a location, that location can be recommended to be placed on Code Red status by any of the management personnel (Team Leaders, Program Coordinators, Program Directors, RN, etc.) All recommendations for Code Red placement will be reviewed by the agency Guidance Team within 2-3 business days from the time of the request. If approved, that location will be placed in the Code Red status immediately.
How will Code Red status be communicated to the team and agency management?

Whenever a location is placed on Code Red status, the Director of that team will issue a copy of the Code Red Notification memo that is used throughout the agency to the identified location. This memo will be copied to the Guidance Team members so that on- call personnel and the agency RN will be notified.
When a location is placed under Code Red status, what is required?
Code Red status required that the following occur:
1)	All medications in this location must be counted during all shift changes. (example: 1st shift will count medications before they leave, the incoming 2nd shift staff must verify that this count is correct when they arrive to work with the outgoing staff present.) Audit sheets for med counts must include the initials of both the incoming and outgoing staff of each count. This means that if a med count is incorrect, the staff person who administered medications on the outgoing shift would be the responsible person for the med error. Med errors will be reported by the standard practice and policy.
2)	Unannounced supervisory visits by the Program Director/designee will increase in this location. Visits will include oversight of medication administration by staff and random med counts will be conducted by management during visits.

How is a location removed from Code Red status?
Each location placed under Code Red status must complete a consecutive 30-day period without any medication errors whatsoever (this included non-signature errors). Once a location has successfully completed this they will resume their routine med audit schedule and increased supervisory visits will cease.
Corrective Action Plan
1)	Progressive disciplinary action will be taken with each staff as errors occur. Each error will be filed in the staff member's personnel record. The disciplinary process for medication errors/omissions/non-signatures will cover a 6-month span of time from the first date of disciplinary. After 6 months, unless a staff has reached the probationary period of this process, the process will be started fresh and the past 6 months disciplinary not counted. If a staff has reached the probationary period of the disciplinary process, it must continue and their disciplinary process will not start over until the full probationary period is completed successfully. The Progressive disciplinary process is as follows:

•	1st offense: Staff receives written verbal warning from Team Leader or Program Coordinator.
•	2nd offense: Staff receives written warning from Team Leader or Program Coordinator & counsel with agency RN.
•	3rd offense: Staff receives last written warning and counsel from Program Director.
•	4th offense: Staffs medication certification is revoked, must re-take 3-day training, and placed on 90-day probation.
•	Last offense: Staff’s employment is terminated (if error occurs within 90-day probation).
2)	In situations where a specific work location has unidentified errors (the person/persons
1)	
responsible for the errors cannot be identified) or numerous identified errors, that team will be placed on Code Red Status. (see Code Red Status Policy).

Section 4: POLICY 103 - PSYCHOTROPIC MEDICATION ADMINISTRATION
POLICY:
BRS, Inc. provides services to individuals that may require psychotropic medication to improve or stabilize a condition that interferes with their quality of life. Medication that is used as part of a Behavioral Support Plan will require the following:

1.	Evaluation and diagnosis in DSM IV format by a Psychiatrist;
2.	A written order including the appropriate medication regimen;
3.	A Mental Health Plan or BSP developed in conjunction with the person's circle of support including the Independent Support Coordinator, and approved as required by DDA policy;
4.	Informed Consent will be obtained if individual is competent;
5.	Administration by licensed or trained personnel; and
6.	Information will be sent to the Independent Support Coordinator. Care Coordinator, Support Coordinator upon request.

Informed Consent Policy is provided in each residential and Day Service Team Leader Medication Administration for Unlicensed Personnel notebook.

Pharmaceutical Guidance:
Per State guidelines any person that receives services through the Department of Intellectual Disabilities, Employment Community First Services, or CLS elderly/Disabled Services must have a Quarterly Medication review on any orders received for Psychotherapy. It is requested that if an individual is on 4 or more Psychotropic medications or 2 or more medications from the same class that an attempt in reduction is made. If the provider feels that the benefit of the medication outweighs the risk, then the provider can choose not to reduce the current medication.

Section 4: POLICY 104 - INFORMED CONSENT
POLICY:
When psychotropic medication is required for treatment other than strictly medical indications, written informed consent will be obtained from the person served, if competent, or the persons guardian/conservator prior to use and reviewed at least one time per year.

PROCEDURE:
Information will be presented in a manner consistent with the communication needs of the person served or his/her guardian/conservator as needed. The information will be presented orally or in writing using layperson's terms.

The Consent Form will be completed and signed by the authorized individual.
Informed consent will not be required for medical treatment using psychotropic medications.

FORMS: Forms are kept in the Program Director’s and/or RN’s office.

STATE OF TENNESSEE
 Department of Disability and Aging Office of Health Services

Medication Administration for Unlicensed Personnel Policy Review

Buffalo River Services, Inc.	submitted policy has been

Name of Agency

reviewed and meets the critical element requirements for acceptance. Policy accepted statewide on	December 9, 2022	.
Date

Deputy Commissioner of Health Services or Designee

Any revision requires submission to a Nurse Educator in the Regional Nursing Department for review and acceptance.
December 9, 2022
Date

c: Electronic File	Nurse Educators

Section 5: POLICY 101 - USE OF POSITIVE APPROACHES
Policy:
BRS, Inc. is committed to providing positive supports to person supported. The use of the most positive, effective and least intrusive support will be implemented for each person.

The providers of behavioral support services will meet standards that establish confidence in evaluation and implementation of best practices as established by funding sources.
Services provided will be consistent with the Behavior Analyst Certification Board (BACB).
Procedure:

The ability of the Agency to implement strategies that provide support services that emphasize a positive approach to person supported who challenges the system will occur at two levels:

1.	Proactive strategies where specialists work alongside support services to promote physical, emotional, and psychological wellbeing. This strategy includes:

•	Timely provision of supports that are individually designed to meet the specific needs of the person;

•	Timely development of coordinated services to manage important transitions;

•	Ongoing efforts to help the person communicate their needs and wants; and

•	Ongoing provision of services in a manner that respects each
person’s wants, desires, and needs.
2.	Reactive strategies that require the Agency to take corrective action after the problem is identified and before an emergency situation. This strategy may include the following:

•	Approximate policy and training with the capacity to respond effectively with minimum intrusion and maximum effectiveness.

•	Effective crisis response and crisis management services that are flexible and adaptive.

•	Organizational planning and development that will optimize the ability of the Agency to respond effectively.
•	
BRS, Inc. prohibits restrictive intervention procedures deemed aversive according to the DDA Operations manual.

Section 5: POLICY 102 – INDIVIDUAL CRISIS INTERVENTION
Policy:
BRS, Inc. is committed to providing a safe environment for all person supported, employees, and support personnel. As situations develop that require intervention in behavioral crisis events, emphasis will be on responses that are timely, safe, and effective.
BRS, Inc. employees shall be trained in Nonviolent Crisis Interventions consistent with contract requirements. Training will also include information needed to assess situations that are problematic and evaluate established efforts for effectiveness related to each person’s needs. Contact protocols for events that place person supported or support staff at risk of harm will be provided as part of the training. Refresher training will be provided annually. Training may be coordinated with other service providers to comply with staffing requirements.

Every effort to provide services that promote physical, emotional, and psychological wellbeing will be made. Assistance in the coordination of specialists or specialized services to meet individual needs for support will be available to reduce or prevent situations requiring behavioral crisis intervention(s).
Procedure:

Supervisory on-call staff will be available by phone to assist in the management of incidents that involve crisis situations and will be trained to evaluate the ability of support staff to provide appropriate support. The on-call supervisor will have access to Behavior Support Plans and Individual Crisis Plans and will have authority to provide additional support staff if required. Emergency numbers will be posted at all locations.

For events that present a risk of harm to person supported or others, staff will contact the on-call supervisor when the event deescalates or when reporting will not interfere with support. The Individual Crisis Plan or Behavior Support Plan information will be used to determine the need for hospitalization or other services. If no plan is available and de- escalation measures are not effective, hospitalization may be required to assess and evaluate as required, and for the safety of all involved as determined by the on-call supervisor.
Emergency transportation services will be used as necessary for hospitalization. If emergency transportation is not available, additional staff will be provided to assist in transportation. A person supported that is in a behavioral crisis will not be transported without sufficient support staff.

If Agency resources cannot provide the necessary support, the local police may be contacted regarding the crisis. Information will be provided as to the specific nature of the behavior and the intellectual disability diagnosis.

Incident reports will be completed, and contact with DDA will be as provided as required in the Protection from Harm Policy. The Independent Support Coordinator/CM will be contacted as part of the incident process and for service changes. The mental health support provider will be contacted, and support staff will review support plans for changes if current plans are not effective.

Individual Crisis Plans will be evaluated to determine effectiveness and future changes or actions as soon as possible.

Changes in support or Individual Crisis Plans may require reevaluation and approval by the oversight committees regarding behavior interventions and human rights, the mental health support provider, the Independent Support Coordinator, and the regional office.

Section 5: POLICY 103 - BEHAVIOR INTERVENTIONS

Policy:
BRS, Inc. will only use interventions that are the most positive, effective and the least intrusive possible to support person supported who challenge the system or services. The focus of interventions will be to build positive behaviors, which will replace or reduce the need for particular challenging behaviors, and to ensure that no unnecessary or inappropriate restraints are used.

Procedure:

Only unrestrictive interventions consistent with outcomes to reduce the person’s use of challenging behaviors will be provided. The approved interventions are listed below with requirements for approval prior to implementation.
a)	The focus of behavioral treatment must be for the prevention of behavioral safety interventions. The use of behavioral safety interventions represents a failure in the treatment provided to the person served;
b)	The use of behavioral safety interventions shall be outlined in the crisis section of the person’s BSP or in an Agency policy for their use. Parameters for a policy regarding behavioral safety interventions may be found in section 12.7.1.c of the March 15 2014 Provider Operations manual;
c)	BSPs involving the use of behavioral safety interventions shall include clear descriptive criteria for the initiation and termination of the procedure. When appropriate, the BSP may refer to the agency’s policy for the initiation and termination of behavioral safety interventions or will seek guidance from the person’s Circle of
a)	
Support;
d)	BSPs that contain behavioral safety interventions and no other restricted, special individualized, or specialized behavioral safety interventions do not require approval by a BSC or HRC;
e)	Any use of behavioral safety interventions that do not conform to the rules stated above or the procedural definitions listed on the DDA website shall require approval by the Statewide BSC as a variance to the DDA Provider Operations manual;
f)	Following the occurrence of a behavior safety intervention as defined by the March 15, 2014, Provider Operations manual, an Agency designee shall conduct a debriefing regarding what worked and did not work with the procedure. The debriefing shall be documented in a daily note;
g)	When a person served has had three (3) uses of a particular behavior safety intervention or PRN medications within the past six (6) months, its use shall be outlined in the crisis section of a BSP. If the person supported does not currently receive behavior services, a behavior services assessment shall be requested.
Reference - Page 179 March 15, 2014 revision on the DDA Provider Operations Manual.

Section 5: POLICY 104 - USE OF RESTRAINT
Policy:
BRS, Inc. support services may include person supported that challenge the system and at times may be a danger to themselves or others. To maintain the quality of life available to them in the community, it may be necessary to formulate a Behavior Support Plan (BSP) developed through consultation with qualified mental health professionals. If more positive techniques are not successful, restricted behavior interventions that include the use of restraints may be considered.

Procedure:
The use of restraints as part of the BSP or in emergency/crisis events will be used only by staff, volunteers, or support providers trained in an approved crisis intervention program that is consistent with the needs of the person supported.

Takedowns and prone restraints are prohibited, as well as restraint vests, the removal of mobility aids, chemical restraint, seclusion or the use of noxious or painful stimuli. BRS, Inc. will use intervention appropriately.

Section 5	Policy 104 Restraints - Addendum
Buffalo River Services, Inc. Non-Violent Crisis Intervention General Training Policy ECF ref. 6.d.1

Buffalo River Services, Inc. teaches Mandt and Associates, Non-Violent Crisis Intervention procedures to give staff the tools they need to directly intervene in crisis situations and teach staff de-escalation techniques. The goal of this training is to help staff learn decision- making skills to match the level of response to the risk of the crisis. The goal of the training is for staff to recognize the stages of an escalating crisis and learn evidence -based techniques to appropriately de-escalate a crisis. This training also provides philosophy to help employees to understand that risk mitigation for injury and trauma is important. The training curriculum engages the staff member in adhering to the agency’s expectation that reducing the use of restrictive measures is highly important and expected.
In keeping with the Buffalo River Services, Inc. policy and commitment to positive supports, Buffalo River Services, Inc. discourages the use of restraints and prohibits take-down prone restraints and staff are advised of this policy during training. Occasional exemptions for standing or sitting manual holds are made if approved by the COS and are agreed upon by the person and/or conservator for safety reasons.
All new staff members go through Mandt training by program supervisors based on their work assignments and need. This training can be requested by any agency employee and management will decide enrollment need based on class availability and employee assignment.	Additionally, at times a staff person may be asked to repeat the training.

+ The Mandt System: A Brief Description: The Mandt System is a training program that has 3 major components: Relational, Conceptual, and Technical. Relational Skills: focuses on teaching relationship, communication, and conflict resolution skills. Conceptual Skills: focuses on teaching positive behavior supports, liability and legal issues, and medical risks of restraint. Technical Skills: training in providing physical assistance, separation, evasion, and restraint techniques.

Section 5: POLICY 105 – GENERAL CRISIS PLAN

Policy:
To protect the safety of person supported by DDA and the Agency personnel who support them.
Procedure:
A.	BRS, Inc. Agency Trainer will be responsible for training staff on monitoring effectiveness of the General Agency Crisis Plan.
A.	
B.	The chairperson of the Risk Management Team will interview support person.
C.	The Chief Executive Officerwill be a member of BRS, Inc. Incident Management Committee.

D.	The Incident Management Committee will review serious incidents and recommend necessary adjustments to Agency Crisis Plan in the minutes.

E.	BRS, Inc. has adopted MANDT and Associates as its training package for crisis intervention.

F.	Each direct support staff at the Agency will receive training in MANDT and Associates Nonviolent Crisis Intervention.
1.	Initial training will be for 24 hours by a certified trainer.
2.	Refresher training will be completed at least once per year for a minimum of three hours as required by management on case by case bases.

G.	BRS, Inc. will have certified trainers on staff.
1.	BRS, Inc. will have at least two certified trainers.

2.	If a trainer leaves the organization, another trainer will be identified and scheduled for the next available certification training.

3.	When appropriate, BRS, Inc. will combine with other agencies to provide certification.

H.	BRS, Inc. will make use of monthly training provided by agencies contracted by the State of Tennessee.
I.	Agency Supervisor Responsibilities:
1.	An Agency supervisor will be on-call during all operating hours to help deal with crisis situations by phone or in person.

2.	Agency supervisors will know how to determine when a support person has lost the ability to carry out appropriate support.

3.	Agency supervisors on-call will have the authority to make strategic staffing changes to aid in the safe resolution of a crisis.

4.	Agency supervisors on-call will have access to the files with Behavior Support Plans and Individual Crisis Plans for all persons deemed vulnerable to crisis within the Agency for reference during a crisis.
1.	
5.	BRS, Inc. will maintain a list of on-call staff who have the ability to perform with supervisory authority.

J.	When a crisis occurs:
1.	In cases where a person is a risk of harm to self or others but the risk is not immediate or severe, support staff will contact the on-call supervisor to report the crisis as soon as possible, provided it does not interfere with providing support. The on-call procedure will be posted and also listed in the Agency policy manual.

2.	When the person has an Individual Crisis Plan that identifies increasing levels of agitation, the Agency supervisor on-call will follow the Individual Crisis Plan in assessing the need for hospitalization or other services.

3.	The on-call supervisor will suggest re-directional options based on the Crisis Questionnaire responses and the MANDT training package. Emergency Restraints will only be used in accordance with DDA policy on Restraint and Protective Equipment in the Manual Restraint section. Take downs or prone restraints are strictly PROHIBITED.

4.	When a person appears to be in need of psychiatric hospitalization, the individual will be transported to the local Emergency Room for evaluation by mobile crisis.

5.	In the Agency service area, this may involve the county sheriff’s office or the police or ambulance if the person will not go to the hospital emergency room willingly.
6.	When a person has been deemed in need of hospitalization, BRS, Inc. would prefer they be admitted to an appropriate facility skilled in working with people with intellectual disabilities.
7.	BRS, Inc. will identify support for the person supported after a crisis if, for some reason, the person cannot immediately return to his/her home.
a.	These include respite locations and short-term hospitalization at a mental health facility for treatment and stabilization.
b.	Temporary housing, if needed, immediately after the crisis situation shall be used for the least possible time. It is important that the person supported know that his/her home is secure and stable, and he/she should return home as soon as possible.
a.	
c.	If short-term supplementation of the program is needed to support the person in his/her own home or in a temporary short- stay location, it shall be requested by the Independent Support Coordinator/CM.
8.	The support staff’s supervisor will review incident reports related to the crisis situation within 24 hours with support staff involved in the crisis.

9.	The supervisor of the support staff involved in the crisis will make any changes to the Individual Crisis Plan of the focus person as soon as the next Incident Management Committee Meeting.

10.	A meeting of the person supported’s team will be called as soon as possible to develop an Individual Crisis Plan for person supported involved in a crisis who do not have an Individual Crisis Plan. Appropriate behavioral services will be obtained to participate in the support team meeting.

11.	In instances where the Mobile Crisis Unit does not respond within 15 minutes and the risk is continual, the on-call supervisor will respond to the crisis in person, assign an augmentative staff, or arrange safe transportation to a local emergency room. Support staff will not transport a person in a crisis alone.

12.	Whenever a person is in an immediate risk of harm to him/herself or others (including, but not limited to, attacks with a weapon) and Agency backup resources cannot provide necessary support, the local police will be contacted by calling 911 and made aware of the crisis. The specific nature of the behavior and the person’s diagnosis will be communicated to the emergency service dPCSPatcher.

EMERGENCY ON-CALL PROCESS
Call (931) 722-3217. Give the person:

-	your name,
-	your location,
-	your telephone number, and
-	the nature of your emergency.

You must give details to determine if the on-call person is to be called or not. If the situation you are calling about can wait until regular business hours, the on-call person will not be called. Your message will be given to them during regular business hours.

You are not to call on-call staff at home. Only use the number listed above.

If an on-call person has not called you within 45 minutes and you need to report an alleged abuse and/or neglect, you are to proceed with calling the DDA State Investigator as noted on the posters the residential home.
Protocol for the answering service only:
Call the person listed as on-call at home. If no answer, call his/her cell phone. If no answer, page him/her. If he/she has not called you in 10 minutes, call the next person on the attached list at home. If no answer, call his/her cell phone. If no answer, call the next person on the list and continue until the list is exhausted.
Start the process once again until someone is reached.
Things we need to know about immediately:

1.	Alleged abuse or neglect;
2.	Someone is being taken to the Emergency Room and/or hospital;
3.	Aggressive behavior of person supported to the point staff are needing physical assistance to handle;
4.	Any disaster;

5.	Someone not reporting to work and the required staffing pattern not met;
6.	Overtime approval when no one else is available.

The person on-call will have his/her cell phone with him/her at all times, other than bed, bath, or shower.

Section 6: POLICY 101 - FIRE AND SANITATION
Policy:
As part of the many safeguards implemented by BRS, Inc., rules and regulations relating to services and facilities will comply with applicable Health Department, Department of Commerce and Insurance, and DDA as required. The use of natural supports as well as individual needs and circumstances will be considered in the evaluation and monitoring process.

Safeguards will be monitored on an ongoing basis to ensure the safety of each individual, and corrective actions will be taken as necessary.
Refer To:
Licensure Regulations
National Fire Protection Association Life Safety Code Fire Drill Policy and Procedures
Staff Training Policy

Procedure:
The Agency, with the assistance of the person supported’s support team, will develop emergency plans to address fire and sanitation issues specifically related to each unique situation and environment.

If specialized equipment or modifications are required, it will be the responsibility of the ISC/CM to develop resources to adapt the environment to be safe and sanitary for each person receiving service. The ISC/CM may provide technical assistance in the development and training for specialized equipment or services.
As required, the Agency will have emergency plans for fire and sanitation issues that address training in evaluation and emergency procedures. These procedures and protocols will be provided in a seamless manner that is sensitive to each individual’s needs.
In the event of a fire or sanitation emergency, procedures will be implemented to resolve the problem in the most safe, efficient, and effective manner.
Fire safety and emergency evacuations are taught as part of Information and Training Specific to the Person across all environments.
Fire and evacuation plans are posted/kept at each site.

Section 6: POLICY 102 - NURITION
Policy:
BRS, Inc. will assist in accommodating persons supported with regard to dietary needs, consistent with mobility, environmental, and personal choice issues.

Procedure:
Accommodations consistent with the PCSP evaluation and treatment plan will be provided for those with significant eating and mobility challenges.

At least a 72-hour supply of food will be kept in each home.

Individual choice regarding menus will be observed unless limited by treatment plans or considered to be a potentially dangerous food.

The following foods can be extremely dangerous if not prepared and consumed in a safe manner:

•	Hot dogs served whole;
•	Grape seeds and outer peel;
•	Dry crumbly foods (i.e. cornbread, rice) served without emollients;
•	
•	Dry particle foods (i.e. ground beef) served without emollients;
•	Whole, raw vegetables served in large bite size;
•	Whole, hard fruits (i.e. pears, apples); and
•	Kernel corn, raisins, whole candy with large nuts.

Section 6: POLICY 103 - PREVENTIVE MAINTENANCE
Policy:
All preventive maintenance of Agency facilities and equipment shall be the responsibility of persons who primarily use the equipment.
Procedure:

The primary drivers of Agency vehicles shall be responsible for minor ongoing and preventive maintenance with approval from the Program Director and ultimately an agency purchase order. This includes oil changes, cleanliness, tires, radiator, battery, and special equipment. The Team Leader shall be responsible for the maintenance and cleanliness of the residential vehicles or appointing someone to see that repairs are completed and the vehicles are clean.

Office equipment maintenance and repair as needed shall be the responsibility of the Vice President of Compliance with proper Chief Executive Officer Board approval dependent on the cost.
Electrical appliance preventive maintenance is the responsibility of persons using such equipment. The repair or replacement of such equipment is the responsibility of the Team Leader and/or Program Director with appropriate approval of the Chief Executive officer or designee and/or Board of Directors dependent upon cost.

The responsibility of a fire extinguisher and smoke detector check lies with the Team Leader. This shall be completed monthly and documented on the "Fire Drill" in the TIMAS database. The Team Leader will submit request for any needed repair or recharge to the administrative office.

Section 6: POLICY 104 - MAINTENANCE OF BUILDING AND EQUIPMENT
Policy:
All employees will be expected to take an active interest in preserving and protecting Agency equipment and physical facilities.
Procedure:
Employees will report promptly via the maintenance request in TIMAS whenever

they detect the need for maintenance services.
The Administrative Assistant shall keep a running list of minor maintenance needs submitted on the appropriate forms. These needs will be prioritized by the Chief Executive Officer or designee and dealt with within the framework of the Agency's operational budget.
All major maintenance needs should be brought to the attention of the Chief Executive Officer in writing on the appropriate form. It will be the responsibility of the Executive Director, along with the CFO, to obtain Board approval and take corrective action as needed within appropriate guidelines.

Section 6: POLICY 105 - VEHICLE REGULATIONS
Policy:
BRS, Inc. maintains vehicles for the transportation of employees, volunteers, persons supported, and support providers on official business.

Procedure:

It is the responsibility of all employees who use Agency vehicles to ensure the safe, efficient, and economical utilization of such vehicles and to be familiar with the provisions of this policy.

Employees and volunteers using personal vehicles for Agency business will be compensated according to Agency travel policy, with advance approval of the Chief Executive Officer or designee. A Certificate of Insurance or acceptable documentation will be required. Priority should be given to the utilization of Agency vehicles whenever possible.
All Agency vehicles shall be used in accordance with the provisions of this policy.
Types of Vehicles

•	Sedans
•	Mini-Vans
•	Vans

Motor Vehicle Record Minimum Requirements
The Agency will not hire anyone to drive an Agency vehicle that has three (3) or more violations in the past year involving a conviction of speeding over 15 miles above the posted speed limit or any driving offense which constitutes a Class A misdemeanor.

Personally Owned Vehicles

BRS, Inc. allows persons supported to be transported in personal vehicles with written approval and proof of all required documentation including a certificate of insurance.
Gas and Oil Refill Procedures

The Agency will maintain a commercial fleet fuel system that will allow authorized staff to purchase fuel and oil at locations providing fuel management services.

Emergency cash or personal credit purchases for oil, gas, or repairs for Agency vehicles paid for by the driver must be explained in writing with receipt to receive reimbursement. Does not include emergency purchases on travel claims.

Maintenance

Maintenance inspections are completed monthly by Team Leaders and/or Program Directors and turned into the office. Any problems with BRS, Inc. vehicles should be reported, in writing, to the supervisor in charge of the vehicle immediately and turned in via maintenance request in TIMAS for approval. Program Staff or designee will schedule repair.
Seizures

In the event a person supported has a seizure while being transported, stop the vehicle as soon and as safely as possible. Wait for the seizure to take its course and take necessary measures to prevent injuries. Depending on the situation, continue with the route or call your supervisor for instructions. In the event of a seizure lasting more than five minutes, take the person supported to the nearest hospital immediately, or call 911. Direct support staff are responsible for documentation of the seizure by the end of the shift.

First Aid
All vehicles are to be supplied with First Aid kits. These First Aid kits are to be checked monthly by the driver for needed supplies. Any needed supplies are to be reported, in writing, to the Team Leader in charge of the particular van. If an injury is severe and needs immediate medical attention, call 911.

Fires
All vehicles are supplied with fire extinguishers that are inspected monthly by the driver. In case of a fire inside or outside the vehicle, stop the vehicle and evacuate immediately. Move persons supported at least 100 feet from the vehicle to ensure safety. Count persons supported to ensure that all have been evacuated and report the incident immediately to the Team Leader.

Disruptive Behavior

When aggression occurs in the van, the driver must pull over out of traffic until the situation is under control. It may be necessary to separate the persons supported and then proceed in traffic. If the situation continues, the driver must seek assistance using any means available. If a person supported has exhibited disruptive behavior while in an Agency vehicle, this must be recorded on an Incident Report. If a person supported is habitually aggressive, the Circle of Support will address the problem as soon as feasible.

Policy: Supervision of Passengers in Agency Vehicles
Purpose: To ensure the safety and well-being of persons supported by Buffalo River Services, Inc. (BRS) while being transported in agency vehicles, adhering to person-centered practices and utilizing the Circle of Support (COS) for decision-making.
Policy Statement: Persons supported by BRS should generally not be left alone in an agency vehicle under any circumstances. This policy is in place to protect the safety of all individuals supported. However, under specific circumstances, leaving a person in a vehicle may be permissible and necessary, provided that proper protocols are followed, and decisions are made with input from the individual's Circle of Support.
Procedures:
1.	General Rule:
o	Persons supported should not be left alone in an agency vehicle. When a driver arrives at a location, all persons supported should accompany the driver inside the building, regardless of the anticipated duration of the driver’s absence.
o	Staff should count the persons supported in the agency vehicle to ensure that everyone is present and accounted for prior to operating the vehicle.
o	Staff should not leave persons supported unattended while running errands at BRS sites or during outings.
2.	Person-Centered Practices:
o	Decisions regarding the supervision of persons supported in vehicles should prioritize the individual's safety, preferences, and needs.
o	The Circle of Support, which includes the individual, their family or guardian, support staff, and other relevant stakeholders, should be consulted to develop and approve a personalized transportation plan for each individual.
o	The transportation plan should outline specific conditions under which a person might be left in a vehicle, including time limits, environmental conditions (such as weather), and the person’s ability to remain safe and comfortable.
3.	Exceptions and Permissible Circumstances:
o	There are occasions where it might be permissible and even necessary to leave a person supported in a vehicle. These exceptions should be clearly documented in the individual's transportation plan and reviewed regularly.
o	Permissible circumstances may include, but are not limited to:
•	Short periods where the individual has expressed a preference to remain in the vehicle and has been assessed as safe to do so by the COS.
•	Situations where moving the individual would pose a greater risk (e.g., severe weather conditions, mobility issues).
•	Instances where the person supported can be easily seen by the support person, and the staff person can quickly return within a few seconds if necessary.
4.	Documentation and Approval:
o	Any decision to leave a person supported in a vehicle should be documented, including the duration, reason, and the name of the staff member responsible.
o	Such decisions should receive prior approval from the COS and be included in the individual's transportation plan.
5.	Training and Accountability:
o	All staff members should receive training on the importance of supervision and the specifics of this policy.
o	Staff should be aware of the individualized transportation plans and the circumstances under which exceptions might apply.
o	Non-compliance with this policy will result in disciplinary action, up to and including termination of employment.
Review and Revision: This policy will be reviewed annually or as needed to ensure it meets the safety needs of persons supported and aligns with person-centered practices and regulatory requirements.
By adhering to this policy, BRS commits to providing a safe, respectful, and person-centered approach to transportation, ensuring that all individuals supported are treated with dignity and their safety is prioritized.

Parking Charges

The user of the vehicle will pay parking charges. Receipts will be sent to the administrative office with the Claim for Travel Expenses form for reimbursement or petty cash request form.
Driving Requirements

All staff providing transportation to the individuals supported at BRS, Inc. must have the proper driver’s license complete with an “F” endorsement. This endorsement must be acquired within 30 days of initial hire date of employment at any Agency facility. Documentation of all employees’ licenses will be kept in personnel in TIMAS. It is the employee’s responsibility to provide personnel with an updated license.

Authorized Operators and Passengers
Only BRS, Inc. employees with proper authorization and the appropriate license will be permitted to operate Agency vehicles.
Passengers shall be limited to employees (within the scope of their employment) volunteers, persons supported, support providers, and authorized guests.

Safety

All BRS, Inc. staff and people supported are required to put on their seatbelts prior to the vehicle being operated and until arriving safely at their destinations. This is the law of the State of Tennessee, as well as safe practice for everyone. In the event that an individual refuses to wear a seatbelt, an Incident Report must be filled out and if the refusal continues, the appropriate personnel should be notified (Team Leader or Program Director).

Wheelchairs must be secured before operating the vehicle. If there is equipment that is non-operable, such as wheelchair tie-downs or seatbelts, this should be reported immediately by completing a Request for Maintenance form in TIMAS so that it will be repaired.

While passengers are boarding and exiting the vehicle, staff are to be at the door of the vehicle to give assistance to anyone who may need it. Staff must tell the passengers to wait to board or exit until a staff member is at the door to help them.
Hazardous Road Conditions

When road conditions are hazardous, all drivers should exercise extreme caution and extra time should be allowed to reach destinations. All riders should have on seat belts, which should be securely fastened. Before operating vehicles under

hazardous road conditions, staff is required to check emergency equipment in the vehicle in case the vehicle becomes inoperable. Staff should have flashlights, flares, and blankets on hand when transporting individuals during winter hazardous weather which should all be inside the First Aid kits.
Conditions for Using Vehicles
The vehicle operator should allow sufficient time for travel and not exceed the speed limit or reduce speed appropriately as road, traffic, and weather conditions dictate.

The driver has the final decision on route matters involving the safety of the passengers and will supervise all passengers as necessary to ensure their safety. All occupants will wear seatbelts as required by OSHA, transportation contract requirements, and Tennessee law.
Clean-Up

Keeping the Agency vehicles clean is in every staff member’s job description. Staff may not pay people supported to clean up the vehicles. It is the civic responsibility of all passengers to remove any trash they may accumulate during the day from the van. This teaches people supported to be responsible people.

Commuting
Agency vehicles may not be used for commuting to and from home unless circumstances indicate the necessity of this use.

Driver Reports

•	Daily trip reports on Log Form
•	Repair request
•	Incident reports - See Protection from Harm Policy

Traffic Violations
All traffic violations issued for unlawful acts that include monetary fines are the responsibility of the driver to either pay or settle in a legal manner. Staff are to report traffic violations to their supervisor. If people supported are in the vehicle when a staff person receives a traffic violation, an incident report form will be completed as a possible risk of harm and possible reportable staff misconduct.

Accidents

Drivers should remain at the scene of the accident, call the police, and notify their Team Leader or the administrative office immediately. The Team Leader will notify the administrative office as soon as possible. Vehicle Accident Report forms are required to be on all vehicles being used for Agency purposes and must be filled out and turned in before the shift ends.
Drivers will be routinely given a drug test if involved in any accident. See drug policy.
Mood-Altering Drugs
Drivers will be disciplined if discovered driving under the influence of any mood- altering drug while on company time, according to BRS, Inc. drug policy.

Misuse of Vehicles
Employees who misuse Agency vehicles and/or endanger passengers will be subject to disciplinary sanctions, depending upon the magnitude of the offense and the frequency with which it has occurred.

All facility-owned vehicles used for person supported transportation and staff- owned vehicles used for Agency business must be adequately covered by vehicular liability
insurance for personal injury to occupants of the vehicle. Documentation of such insurance will be maintained at the administrative office.

TDOT Vehicles
All vehicles we receive through DOT grants will be disposed of according to FTA Circular. If a vehicle is disposed of before 5 years passes, TDOT will be notified and if sold, the money will be put back into the transportation budget or will be returned to TDOT.

Section 6: POLICY 106 – UNIVERSAL PRECAUTIONS
Policy:
It is the policy of BRS, Inc. to protect persons supported, visitors, employees, and volunteers from the spread of infection by the use of appropriate Universal Precautions and adequate isolation procedures.

BRS, Inc. will assist persons supported with access to immunizations as consistent with their needs and with consent. Persons supported are required to complete an immunization consent form.

Procedure:

In the result of indications of possible infectious disease, further action will be taken as recommended by a physician.

An employee who gives evidence of any infectious condition will not be permitted to work until his/her physician states that he/she is no longer infectious.

In case of an outbreak of influenza in the community, visiting may be discontinued until it is determined that the danger no longer exists.
If it is suspected or made known that a resident has an infection which could be transmitted to others, the Program Director contacts the physician or county health department immediately and follows the instructions given. In the event that the physician or county health department staff cannot be reached by phone, the Program Director will institute isolation procedures immediately if, in his/her judgment, the infection is a source of danger to other persons supported. The physician, the physician's nurse, or county health department will be requested to come to the Agency to instruct staff and support providers regarding isolation techniques for handling the infection.

When persons supported have an oral temperature equal to or greater than 100 degrees, the recommendations of the physician will be followed regarding any actions and/or treatment, as to changes in scheduled services, activity level, individual needs, and isolation procedure required to limit exposure to others.
Any event requiring infectious control procedures by the Agency for people supported will be reported as required in the Protection from Harm Policy, and in compliance with contract and Licensure guidelines.

Direct Support Professionals and others performing housekeeping and laundry chores will use Universal Precaution measures, taught in initial training, to prevent the spread of infection to other areas.

EXPOSURE TO BODY FLUIDS
POLICY:
Agency staff routinely follows procedures to minimize the risks of transmission of communicable diseases. These guidelines provide simple and effective precautions for all staff members who may be exposed to the body fluids of any individual in the work setting.
PROCEDURES:
In this policy, “employee” is defined as any person (e.g., an employee, student, contractor, attending clinician, public-safety worker, or volunteer) whose activities involve contact with patients or with blood or other body fluids from patients in a health-care or laboratory setting. An "exposure" that may place an employee at risk for HIV infection and therefore

requires consideration of PEP (Post Exposure Prophylaxis) is defined as a percutaneous injury (e.g., a needle stick or cut with a sharp object), contact of mucous membrane or no intact skin (e.g., when the exposed skin is chapped, abraded, scratched, bitten or afflicted with dermatitis), or contact with intact skin when the duration of contact is prolonged (i.e., several minutes or more) or involves an extensive area, with blood, tissue, or other body fluids.
Body fluids include:
a)	semen, vaginal secretions, or other body fluids contaminated with visible blood that have been implicated in the transmission of HIV infection (11, 12); and
b)	cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids, which have an undetermined risk for transmitting HIV (11).
In addition, any direct contact (i.e., without barrier protection) to concentrated HIV in a research laboratory or production facility is considered an "exposure" that requires clinical evaluation and consideration of the need for PEP.
Note: In the absence of visible blood in the saliva, exposure to saliva from a person infected with HIV is not considered a risk for HIV transmission; also, exposure to tears, sweat, or non-bloody urine or feces does not require post-exposure follow-up.
"Body fluids" or "blood borne exposure" apply to blood, drainage from scrapes and cuts, feces, urine, vomit, saliva and drainage from any orifice (e.g. nose, ears).
Staff should practice the following procedures:
a.	Avoid direct skin contact with body fluids of others when possible.
b.	Gloves should be worn when direct hand contact with body fluids is anticipated. For example, gloves should be worn when treating bloody noses, handling clothes soiled by incontinence or vomit, cleaning small spills by hand, changing adult briefs, and assisting customers in personal hygiene (bathing, brushing teeth, etc.).
c.	After removal of personal protective gloves, employees shall wash hands and any other potentially contaminated skin area immediately or as soon as feasible with soap and water. If employees incur exposure to their skin or mucous membranes then those areas shall be washed or flushed with water as appropriate as soon as feasible following contact.
d.	Gloves and other materials used for this purpose should be put in a plastic bag and placed in a lined trashcan. Plastic bags should be changed daily and disposed of routinely. Double bagging can be used when there is a high risk of contamination.
e.	Gloves should be kept in all areas, including first aid kits, restrooms, maintenance areas, offices and any rooms where the risk of spills is high.
f.	Customers should be taught to handle their own body fluids as appropriate for age and state of health.
g.	Customers should be taught proper hand washing techniques and encouraged to use them routinely (i.e. before eating, after toileting, etc.). Proper hand washing requires the use of soap and water and vigorous washing under a stream of water for 10 seconds. Thorough drying of hands after washing is necessary.
a.	
h.	When direct skin contact or contamination of materials occurs from unanticipated skin contact with body fluids, proper cleaning techniques should be followed.
i.	Hands and other affected skin areas of the exposed person should be routinely washed with soap and water after contact. Liquid soap is preferable. Fingernails should be kept trimmed and clean.
j.	Clothing items that are soaked through to the skin should be removed, placed in a plastic bag and sent home for laundering. Items laundered for organization use or in the Agency should be washed with detergent in a hot water cycle before re use. If low temperature laundry cycles are used, chemicals suitable for low temperature washing should be used.
k.	Personal Protective Equipment
l.	All personal protective equipment used at Buffalo River Services, Inc. will be provided without cost to employees. Personal protective equipment will be chosen based on the anticipated exposure to blood or other potentially infectious materials. The protective equipment will be considered appropriate only if it does not permit blood or other potentially infectious materials to pass through or reach the employees’ clothing, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time for which the protective equipment will be used.
m.	Protective clothing will be provided to employees in the following manner:
n.	Gloves will be procured as needed and stored in areas accessible to all staff. Where danger of bites or scratches, long sleeves will be worn.
o.	All garments that are penetrated by blood shall be removed immediately or as soon a feasible. All personal protective equipment will be removed prior to leaving the work area.
p.	Gloves shall be worn where it is reasonably anticipated that employees will have hand contact will blood, other potentially infectious materials, non-intact skin, and mucous membranes. Disposable gloves used at Buffalo River Services, Inc. are not to be washed or decontaminated for re-use and are to be replaced as soon as practical when they become contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.
q.	Utility gloves will be discarded if they are cracked, peeling, torn, punctured, or exhibits other signs of deterioration or when their ability to function as a barrier is compromised.
r.	The OSHA standard also requires appropriate protective clothing to be used, such as lab coats, gowns, aprons, clinic jackets, or similar outer garments. The following situations require that such protective clothing be utilized: Aprons and/or smocks should be requested by employees for use in cleaning and washing laundry.

Laundry Procedures
a.	Laundry contaminated with blood or other potentially infectious materials will be handled as little as possible. Such laundry will be placed in appropriately marked bags at the location where it was used. Such laundry will not be sorted or rinsed in the area of use.
b.	All employees who handle contaminated laundry will utilize personal protective equipment to prevent contact with blood or other potentially infectious materials.
a.	
c.	Contaminated disposed items (tissues, paper towels, and adult briefs) should be handled with disposed gloves. Clothing of staff should be protected, especially of staff that may be at frequent high risk for contact with body fluids
d.	Smocks are recommended for use in some areas or when staff members are tending sick individuals. Smocks will protect staff from contamination with body fluids and can be removed when staff leaves the area. Such procedures help prevent unknown/unnecessary transmission of disease.
e.	Clothing and smocks should be laundered as previously described.
f.	Spilled body fluids should be removed from the environment by proper cleaning techniques. Spill Kits should be used.
g.	Contaminated surfaces should be thoroughly cleaned with a freshly prepared solution containing one cup of household bleach per gallon of water. A germicide can be substituted if a bleach solution is unavailable. Disposed gloves should be worn.
h.	Wastes and disposed cleaning equipment should be placed in a toilet or plastic bag as appropriate.
i.	Non-disposed cleaning equipment (mops, buckets) should be thoroughly rinsed in a bleach solution. The bleach solution should be poured out promptly.
j.	Janitorial responsibilities include daily cleaning with bleach/germicide in areas particularly where contact with body fluids is likely (restrooms, sinks, toilets, etc.). Spilled bodily fluids on carpets should be dPCSPosed of by the routine use of a moisture absorbent on the carpet, which is then swept or vacuumed. The spill should then be reported to the Team Leader in order to have carpets professionally cleaned.
Needles
Contaminated needles and other contaminated sharps will not be bent, recapped, removed, sheared or purposely broken. OSHA allows an exception to this if the procedure would require that the contaminated needle be recapped or removed and no alternative is feasible and the action is required by the medical procedure. If such action is required then the recapping or removal of the needle must be done by the use of mechanical device or a one- handed technique. At Buffalo River Services, Inc. recapping or removal is only permitted by licensed medical personnel as ordered by a doctor or emergency situations.
Containers for Reusable Sharps
Contaminated sharps that are reusable are to be placed immediately, or as soon as possible, after use into appropriate sharps containers. At Buffalo River Services, Inc. the sharps containers are puncture resistant, labeled with a biohazard label, and are leak proof.
k.	This agency’s work sites and Day Service areas will be cleaned and decontaminated twice per week unless specific contamination occurs, and then it will be done as needed. Home and residential areas are cleaned and decontaminated daily.
l.	Decontamination will be accomplished by utilizing the following materials: bleach and water mixture or germicide such as Virex or other registered germicide. All surfaces will be decontaminated after completion of procedures and immediately or as soon as feasible after any spill of blood or other potentially infectious materials,
a.	
as well as the end of the work shift if the surface may have become contaminated since the last cleaning.
m.	All bins, pails, cans, and similar receptacles shall be inspected and decontaminated on a regularly scheduled basis by Direct Support Staff in residential locations and by janitorial in administrative and day buildings.
n.	Any broken glassware that may be contaminated will not be picked up directly with the hands. The glass should be removed with the use of a scoop type tools such as a dustpan or shovel etc. The tool should have protective sides and back to prevent the glass from pushing up against skin. Broken glass should be discarded by double bags and then placing into some other impenetrable container such as a cardboard box, labeled and then placed in appropriate trash container.

Work Area Restrictions
In work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious materials, employees are not to eat, drink, apply cosmetics or lip balm, smoke, or handle contact lenses. Food and beverages are not to be kept in refrigerators, freezers, shelves, cabinets, or on counter tops or bench tops where blood or other potentially infectious materials are present. Mouth/pipetting/suctioning of blood or other potentially infectious materials is prohibited. All procedures will be conducted in a manner that will minimize splashing, spraying, splattering, and generation of droplets of blood or other potentially infectious materials.
Specimens
Specimens of blood or other potentially infectious materials will be placed in a container that prevents leakage during the collection, handling, processing, storage and transport of the specimens. The container used for this purpose will be labeled or color-coded in accordance with the requirements of the OSHA standard. Any specimens that could puncture a primary container will be placed within a secondary container that is puncture resistant.
Contaminated Equipment
Equipment which has become contaminated with blood or other potentially infectious materials shall be examined prior to servicing or shipping and shall be decontaminated as necessary unless the contamination of the equipment is not feasible.
All employees have been identified as having potential exposure to blood or other potentially infectious material.
All staff will be offered the Hepatitis B vaccine at no cost to the employee.
The vaccine will be offered within 10 working days of the employee's initial assignment to work involving the potential for occupational exposure to blood or other potentially infectious materials unless the employee has previously had the vaccine.
Employees who decline the Hepatitis B vaccine will sign a waiver that uses wording in compliance with OSHA standards.

Employees, who initially decline the vaccine but who later wish to have it, may then have the vaccine provided at no cost.
It is the employee’s responsibility to make an appointment with the agency RN for their
Hepatitis B vaccination.
Upon any exposure to potential HBV, employees should and are encouraged to request an HBV titer be drawn to determine that their HBV immune level is still active. If the blood test shows the need for a booster shot, a booster HBV will be given and another HBV titer drawn after 2 months to insure the level is back where it should be. All of this will be filed under the Agency’s worker’s compensation policy, due to exposure.
Anytime after 10 years of employment with our agency, if the employee wishes to have a blood test to determine if the HBV is still active, they may do so at their own expense. If the blood test shows that a booster HBV is needed, the Agency will pay for the HBV injection under the same terms as for a new employee. The employee should furnish the Agency with a copy of the blood test result prior to receiving the booster injection. Two months after the booster, the Agency will pay for an HBV titer to determine that the HBV level is back where it should be. If not, the Agency will pay for additional booster(s) under the same terms and conditions as for new employees.
Exposure Control Procedures
We follow OSHA #CFR 1910.1030
In accordance with the OSHA Blood borne Pathogens standard, 29 CFR 1910.1030, the following exposure control plan has been developed:
Exposure Determination
OSHA requires employers to perform an exposure determination concerning which employees may incur occupational exposure to blood or other potentially infectious materials. The exposure determination is made without regard to the use of personal protective equipment (i.e. employees are considered to be exposed even if they wear personal protective equipment).
This exposure determination is required to list all job classifications in which all employees may be expected to incur such occupational exposure, regardless of frequency. An exposure does not have to be co-occurring with an injury to be defined as an exposure incident.
PEP Step 1: Treat Exposure Site as follows:
1.	Use soap and water to wash areas exposed to potentially infectious fluids as soon as possible after exposure,
2.	Flush exposed mucous membranes with water,
3.	Flush exposed eyes with water or saline solution, and
4.	Do NOT apply caustic agents, or inject antiseptics or disinfectants into the wound.
1.	
PEP Step 2: Report and Document
Report occupational exposures immediately; circumstances of the exposure and PEP management should be recorded in the exposed BUFFALO RIVER SERVICES, INC. STAFF MEMBER’s confidential medical record. Details should include:
1.	Date and time of exposure;
2.	Details of the incident: where and how the exposure occurred:
a.	exposure site(s) on BUFFALO RIVER SERVICES, INC. STAFF MEMBER’s body;
b.	if related to sharp device, the type and brand of device.
3.	Details of the exposure:
a.	type and amount of fluid or material;
b.	severity of exposure.
4.	Details about the exposure source:
a.	Whether the source material contained HIV, HBV or HCV;
b.	If the source patient is HIV infected, determine stage of
i.	disease, viral load, history of antiretroviral therapy,
ii.	antiretroviral resistance information if known, and
iii.	Details about the exposed BUFFALO RIVER SERVICES, INC. STAFF MEMBER: hepatitis B vaccination, and
c.	Vaccine-response status, other medical conditions, and
d.	Medications, including pregnancy or breast-feeding.
5.	Document counseling, postexposure management and follow-up.
PEP Step 3: Evaluate the Exposure
The exposure should be evaluated for potential to transmit HBV, HCV, or HIV based on the type of body substance involved, the route, and severity of exposure.
Significant exposures to any of the following may pose a risk for bloodborne pathogen (BBP) transmission and require further evaluation:
•	Blood
•	Cerebrospinal fluid
•	Peritoneal fluid
•	Semen • Synovial fluid
•	Pericardial fluid
•	Vaginal secretions
•	Pleural fluid
•	Amniotic fluid

Body fluids that do NOT pose a risk of BBP transmission unless visibly bloody include:
•	Urine
•	Stool
•	Tears
•	Sputum
•	Emesis
•	Sweat
•	
•	Saliva
•	Nasal Discharge

Factors to consider in assessing the need for follow-up:
•	Type of exposure;
•	Percutaneous injury;
•	Membrane exposure;
•	Nonintact skin exposure;
•	Bites resulting in blood exposure to either person involved;
•	Type and amount of fluid/tissue;
•	Blood;
•	Fluids containing blood;
•	Potentially infectious fluid or tissue;
•	Direct contact with concentrated virus;
•	Infection status of source patient;
•	If positive for HBsAg, consider testing for presence of HBeAg;
•	If positive for HCV antibody, consider measuring HCV viral load;
•	If positive for HIV antibody, consider measuring HIV viral load and clinical status of
Patient;
•	Susceptibility of exposed BUFFALO RIVER SERVICES, INC. STAFF MEMBER
•	Hepatitis B vaccine and vaccine response status; and
•	HBV, HCV, and HIV status—baseline testing for HbsAb, anti-HCV, and HIV antibody should be completed as early as possible (preferably within 72 hours).
PEP Step 4: Evaluate the Exposure Source When source patient is known:
•	Test patient for HBsAg, HCV antibody and HIV antibody;
•	Viral load assessments for routine screening of source patients are NOT
recommended;
•	Consider using a rapid HIV-antibody test;
•	If the source person is NOT infected with a BBP, baseline testing or further follow- up of BUFFALO RIVER SERVICES, INC. STAFF MEMBER is not necessary
•	Follow state regulations related to informed consent and confidentiality; and
•	For patients who cannot be tested, consider medical diagnoses, clinical symptoms,
and history of risk behaviors.

When source patient is NOT known:
Evaluate the likelihood of high-risk exposure:
1.	Consider the likelihood of bloodborne pathogen infection among patients in the exposure setting, i.e. what is the community infection rate?
2.	Does the clinic/hospital unit care for a large number of HIV-infected or at-risk patients?
3.	Do not test discarded needles for bloodborne pathogens; the reliability of these findings is not known.
1.	
PEP Step 5: Disease-Specific PEP Management
Baseline testing of all exposed BUFFALO RIVER SERVICES, INC. STAFF MEMBERS should be performed for ALL exposures.
Post-Exposure Evaluation and Follow-up
When the employee incurs an exposure incident, it should be reported to the staff injury coordinator and to the supervisor immediately. All employees who incur an exposure incident will be offered post-exposure evaluation and follow-up in accordance with the OSHA standard. The employee should call their Program Director if during regular office hours or the on-call person if after hours to report any exposure incident. At that point, a decision will be made regarding the post exposure follow up immediately. The person will have to see an approved physician or an emergency room doctor to obtain the post exposure medical evaluation and following recommendations and treatment.
This follow-up will include the following:
1.	Documentation of the route of exposure and the circumstances related to the incident, if possible;
2.	The identification of the source individual; and
3.	If possible, the status of the source individual. The blood of the source individual will be tested (after consent is obtained) for HIV/HBV infectivity.

Results of testing of the source individual will be made available to the exposed employee with the exposed employee informed about the applicable laws and regulations concerning disclosure of the identity and infectivity of the source individual.
The employee will be offered the option of having their blood collected for testing of the employee’s HIV/HBV serological status. The blood sample will be preserved for at least 90 days to allow the employee to decide if the blood should be tested for HIV serological status. The employee may refuse treatment; however, testing should continue to be encouraged.
However, if the employee decides prior to that time that testing will be conducted, the appropriate action can be taken and the blood sample discarded. If treatment for HIV prophylaxis is to be implemented it must be done very quickly and the staff member shall not wait to decide because the option is time limited due to decreased effectiveness of the treatment if one waits too long.
The employee will be offered post exposure prophylaxis in accordance with the current recommendations of the U.S. Public Health Service. A licensed physician or nurse practitioner will assess this and that medical professional will operate in accordance with the protocol established by the recommendations of the U.S. Public Health Service. A study of healthcare workers found that treatment with AZT shortly after a needle stick (post- exposure) reduced the odds of subsequent HIV infection by almost 80 percent. Post-

exposure prophylaxis (or PEP, as it is commonly called) involves taking antiretroviral medications shortly after exposure to HIV.
The employee will be given appropriate counseling concerning precautions to take during the period after the exposure incident. The employee will also be given information on what potential illnesses to be alert for and to report any related experiences to appropriate personnel.
Follow-up of exposed BUFFALO RIVER SERVICES, INC. STAFF MEMBER, post exposure testing of BUFFALO RIVER SERVICES, INC. STAFF MEMBER or any employee with occupational exposure to HIV should include follow-up counseling, post exposure testing, and medical evaluation regardless of whether they receive PEP. HIV-antibody testing by enzyme immunoassay should be used to monitor BUFFALO RIVER SERVICES, INC. STAFF MEMBER for seroconversion for >6 months after occupational HIV exposure. After baseline testing at the time of exposure, follow-up testing could be performed at 6 weeks, 12 weeks, and 6 months after exposure. Extended HIV follow-up (e.g., for 12 months) is recommended for BUFFALO RIVER SERVICES, INC. STAFF MEMBER who become infected with HCV after exposure to a source co infected with HIV and HCV. Whether extended follow-up is indicated in other circumstances (e.g., exposure to a source co-infected with HIV and HCV in the absence of HCV seroconversion or for exposed persons with a medical history suggesting an impaired ability to mount an antibody response to acute infection) is unclear and will be decided upon by a doctor. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Post exposure Prophylaxis.
The Agency contact:
The following person(s) has been designated to assure that the policy outlined here is effectively carried out as well as to maintain records related to this policy: The agency Safety Committee Chair and the staff member’s Program Director.
Interaction with Health Care Professionals
A written opinion shall be obtained from the health care professional who evaluates employees of Buffalo River Services, Inc. Written opinions will be obtained in the following instances:
1)	When the employee is sent to obtain the Hepatitis B vaccine.
2)	Whenever the employee is sent to a health care professional following an exposure incident.
3)	Whenever there is an exposure the staff member will be required to follow all the treatments prescribed by the doctor in order to qualify for the workers compensation insurance benefits.
Buffalo River Services, Inc. will be informed of all procedures, testing and outcomes of treatments until the doctor releases the individual. The human resource personnel will maintain confidentially. Health care professionals shall be instructed to limit their opinions to:

1)	Whether the Hepatitis B vaccine is indicated and if the employee has received the vaccine, or for evaluation following an incident.
2)	That the employee has been informed of the results of the evaluation, and
3)	That the employee has been told about any medical conditions (exposure to HIV/HBV) resulting from exposure to blood or other potentially infectious materials. (Note that the written opinion to the employer is not to reference any personal medical information).

A summary of the steps that must be taken for Pathogen Exposure:
1)	The staff member reports the injury/exposure immediately after applying first aid and cleaning the area of contact of exposure. It does not have to be an injury to be an exposure. For example, being splashed in the face with blood droplets or large volume of blood. Also, even if the employee thinks that it is common knowledge that the source person is non-infected with a pathogen, it is still an exposure incident.
2)	The employee should call their Program Director if during regular office hours or the on-call person if after hours to report any exposure incident. At that point a decision will be made regarding the post exposure follow up immediately. The person will have to see an approved physician or an emergency room doctor to obtain the post exposure medical evaluation and following recommendations and treatment.
3)	The employee must decide on seeking medical attention immediately. PEP (Post exposure prophylaxis) must be initiated within a few hours not days.
4)	The employee follows workers compensation guidelines for seeking medical attention and follow-up.
5)	The employee must follow the medical practitioner’s treatment plan without waiver.
6)	The employee must be tested immediately for a baseline of possible pathology unless the employee refuses at which time the agency will not be responsible for future developments of the employee’s condition related to the work injury and/or exposure incident.
7)	The employee may refuse testing and treatment but must sign a statement stating the refusal.
8)	All records must be presented and filed with the administrative office.
9)	The employee is responsible for reporting to Buffalo River Services, Inc. administration of results of testing and treatments until final results are obtained and treatment stops.
Training
Training for all employees will be conducted prior to initial assignment to tasks where occupational exposure may occur. Training will be conducted in the following manner:
1.	Training for employees will include the following explanations:
a.	The OSHA standard for Blood borne Pathogens;
b.	Epidemiology and symptomatology of blood borne diseases; and
c.	Modes of transmission of blood borne pathogens.
2.	This Exposure Control Plan, i.e. points of the plan, lines of responsibility, how the plan will be implemented, etc.;
3.	Procedures that might cause exposure to blood or other potentially infectious materials
at Buffalo River Services, Inc.;

4.	Control methods that will be used at the facility to control exposure to blood or other potentially infectious materials;
5.	Personal protective equipment available at Buffalo River Services, Inc. and who should be contacted concerning Post Exposure evaluation and follow-up;
6.	Signs and labels used at the facility; and
7.	Hepatitis B vaccine program at the facility.

Compliance Methods
Universal precautions will be observed at Buffalo River Services, Inc. in order to prevent contact with blood or other potentially infectious material.
1.	All blood or other potentially infectious material will be considered infectious regardless of the perceived status of the source individual.
2.	Engineering and work practice controls will be utilized to eliminate or minimize exposure to employees at Buffalo River Services, Inc. Where occupational exposure remains after institution of these controls, personal protective equipment shall also be utilized. At Buffalo River Services, Inc. the following engineering controls will be utilized: (such as sharps containers, appropriate clothing, i.e. long sleeves, etc.)
3.	The above controls will be examined and maintained on a regular schedule. The schedule for reviewing the effectiveness of the controls is as follows: The Program Director, Team Leader or any member of the Guidance Team upon making unannounced or announced visits.
4.	Hand washing facilities are also available to the employees who incur exposure to blood or other potentially infectious materials. OSHA requires that these facilities be readily accessible after incurring exposure. Bathrooms are available in all facilities and also, other antiseptic cleansers are available in conjunction with a clean cloth/paper towel or antiseptic towelettes. If these alternatives are used, then the hands are to be washed with soap and running water as soon as feasible.
5.	Exposure Control Manual with complete procedures will be kept in the Program
Director/Team Leader’s office at each facility.
ALL FORMS that this procedure requires to be completed MUST BE COMPLETED in their ENTIRETY. This includes but is not necessarily limited to the following forms:
•	Checklist for Exposure Control Incidents;
•	Copy of OSHA standard (CFR 1910.1030);
•	Confidential exposure incident report (description of the exposed employee’s duties as they relate to the exposure incident and documentation of the route(s) of exposure and circumstances under which exposure occurred);
•	Refusal of medical treatment form;
•	Source individual HIV/HBV status (if known);
•	Refusal of HBV vaccine;
•	All medical records relevant to the appropriate treatment of the employee including vaccination status (form 7.1);
•	Source individual identification (if known);
•	Physician Referral letter;
•	
•	Physician evaluation form and follow-up form, if needed, with all testing and recommendations listed. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Post Exposure Prophylaxis.

Section 6: POLICY 107 – FIRST AID

Policy:
BRS, Inc. will maintain First Aid kits in all locations that are accessible and well supplied.

Procedure:
1.	Accessibility - First Aid kits are easily accessible and are not locked.
2.	Locations – First Aid kits are maintained in a central location in all residential and supportive living homes, offices and vehicles.
Contents –
•	Flashlights Flares
•	Blankets
•	Assorted size Band-Aids 1 Roll cloth tape
•	1 Space blanket
•	1 CPR mask with one-way valve
•	1 Instant cold compress
•	2 Pair large size gloves 1 Pair scissors
•	1 Three inch rolled bandage
•	2 One to four inch rolled bandage
•	1 to 5 Sterile 3x3 gauze pads
•	1 to 5 Sterile 4x4 gauze pads
•	1 Oral thermometer with probe covers
•	2 Triangular bandages
•	1 Pair tweezers
•	First Aid instruction booklet
3.	Security – First Aid kits are readily accessible and are not locked.
4.	Periodic review and restocking – Staff are to turn in a request immediately when something is missing and when something is used; it must be replaced. First Aid kits are reviewed and restocked monthly by Team Leaders and van drivers.
1.	
Section 7: POLICY 101 - RESPECT
Policy:
BRS, Inc. will recognize the unique circumstances of each person supported. Individual needs, circumstances, choices, and dreams will be recognized and relationships will be developed that provide support and services that reflect the importance of each person’s self- determination and decisions.
Refer to the Advocacy Policy.
Procedure:

As a part of the comprehensive employee development program, issues relating to appropriate interaction with person supported may be included.

Section 7: POLICY 102 - CONFIDENTIALITY/HIPAA
Policy:
BRS, Inc. will provide all reasonable and appropriate measures to maintain information regarding person supported in a manner that will protect confidential information from unauthorized release, misuse, or access.

The Agency complies with the Health Insurance Portability and Accountability Act (HIPAA) mandated by law as of September 20, 2013. The Agency has a designated Privacy Officer, has levels of access for staff, obtains signed confidentiality statements from all staff, has establish disciplinary actions for staff who do not adhere to HIPAA-related polices and assures that protected health information is not left unattended or visible in public areas.
A complete copy of this policy is located in the HIPAA Compliance Officer’s office.

Procedure:
Access to information will be provided to person supported, staff members, and support providers that have a legitimate purpose.

An appropriate release form that includes the purpose and specific requirements will require the person supported signature or authorized individual prior to releasing information.

Reports that involve data collection will limit inclusion of information that may be linked by name.

The Privacy Officer is responsible for development and implementation of HIPAA compliant policies and procedures and for responding to HIPAA related complaints.

Section 7: POLICY 103 - PROTECTION OF RIGHTS

Policy:
BRS, Inc. will protect the rights of all participants. These rights include: The Civil Rights act of 1964 (Title VI), The Age Discrimination Act of 1967 and Amendments, The Vocational Rehabilitation Act of 1973, Americans with Disabilities Act of 1990, The Civil Rights Act of 1991, Title 33 (TCA 33-1-202), and the First Amendment Rights to communicate and assemble.
Procedure:
All persons supported shall be entitled to the following rights without limitation (refer to DDA Provider Policy Manual 2.1.a.):
1.	To be treated with respect and dignity as a human being.
2.	To have the same legal rights and responsibilities as any other person unless otherwise
3.	limited by law.
4.	To receive services regardless of gender, race, creed, marital status, national origin, disability or age.
5.	To be free from abuse, neglect and exploitation.
6.	To receive appropriate, quality services and supports in accordance with an Person Centered Support Plan (PCSP).
7.	To receive services and supports in the most integrated and least restrictive setting that is appropriate based on the particular needs of the person supported.
8.	To have access to DDA, DOH and any other public agencies rules, policies and procedures pertaining to services and supports;
9.	To have access to personal records and to have services, supports and personal records explained so that they are easily understood.
10.	To have personal records maintained confidentially.
11.	To own and have control over personal property, including personal funds.
12.	To have access to information and records pertaining to expenditures of funds for services provided.
13.	To have choices and make decisions.
14.	To have privacy.
15.	To receive mail that has not been opened by provider staff or others unless the person or family has requested assistance in opening and understanding the contents of incoming mail.
16.	To be able to associate, publicly or privately, with friends, family and others.
17.	To have intimate relationships with other people of their own choosing.
18.	To practice the religion or faith of one’s choosing.
19.	To be free from inappropriate use of physical or chemical restraint.
20.	To have access to transportation and environments used by the general public.
21.	To be fairly compensated for employment.
22.	To seek resolution of rights violations or quality of care issues without retaliation.
23.	To have doors that lock from the inside and outside on their private bedroom, as well as a key for such lock. All residents of homes operated by Buffalo River
1.	
Services, Inc. shall have the right to lock their private bedroom doors as they wish. If for safety reasons or other well-being concerns the management deems it necessary to have locks altered or incapacitated in any fashion, there must be approval by the appropriate Human Rights Committee action, the Circle of Support, and the modification must be properly documented pursuant to the Home and Community Based Services Settings Final Rule (see 42 C.F.R. §441.301© (vi) (F).
24.	Documentation for a restriction of this nature will be maintained in the person’s
Person Centered Support Plan and other appropriate written material.

The organization will provide person supported with instruction and opportunities to exercise their rights and procedures to follow if their rights are restricted or violated.
If a person supported rights are restricted or violated, the response by BRS, Inc. will comply with state contract guidelines regarding rights violations.

Refer To:
Protection from Harm Policy Human Rights Committee Policies Staff Training Policy
DDA 1998-50
Communication Rights Policy

All incidents of rights violations will be referred to the Incident Management Coordinator for investigation in a timely manner. The investigation of the violation will be reported on the incident report form and processed in a manner consistent with DDA guidelines.
Rights violations will also be reported to federal and state agencies as required by law.
Limitations on rights must be recommended by the Interdisciplinary Team and approved by Human Rights Committee and Regional Director. Any limitation on rights MUST be approved by court order or law before it is put into practice.

Buffalo River Services, Inc. will:
•	Expect that all Agency members understand that the concept of “rights” goes far beyond the initial training and annual review that is required in most state systems. Rights are all encompassing and are not restricted to “service” or “treatment” rights.
•	Incorporate the Universal Declaration of Human Rights of the United Nations (attached to this policy and procedures) and the constitution of your nation in your training and expect that all staff members, person supported, and other interested parties understand these documents.
•	Establish a culture in which adults are seen and treated as adults regardless of their disability.
•	Host on-going conversations about rights and responsibilities with staff
•	
members and person supported to improve people’s understanding of
these issues.
•	Support people to become politically active through voting, writing letters to the editor, and working with or meeting with their legislative representatives at all levels of government.
•	Prohibit standing policies and practices that restrict rights.
•	Ensure that appropriate staff are educated on the Grier order, specifically on its compliance requirements in relation to Medicaid waiver and ensuring that services are provided in full as authorized in the PCSP and that services must be provided consistently and timely, ensuring that there are no gaps in service delivery. Appropriate staff are those who are directly or indirectly involved in ensuring that services are provided consistently and timely, are responsible for scheduling and employing direct care staff, and are responsible for health care management and oversight or involved in obtaining service authorizations.
The exercise of rights carries with it responsibilities, such as:
•	Provide opportunities for people to think about their rights in all situations and the responsibilities that result from the choices they make.
•	People may choose to carry all the money they have for spending this month with them, but if they spend it all in one day they will not have more for later in the month.
•	A person may choose to get married and will have to manage the possible loss of social security benefits that could occur.
•	Someone may choose to drink alcohol, but may have to go to work with a hangover the next morning.
•	A person may choose to hire an attractive staff person, but the staff may not have the skills necessary to do the work well.
•	Encourage people to think through these consequences and then support the person to experience the consequences for themselves. We learn best through our mistakes not our successes.
•	Agencies have responsibilities too. The Agency would restrict rights in the event a person is likely to harm herself or others or do property damage – in the same way the Agency would restrict rights for anyone in the same situation. We stop people who are breaking the law or acting seriously irresponsibly – sitting in the middle of a street, driving while obviously drunk, etc.
•	The Agency does not restrict rights when people do things that are simply irresponsible or unwise – bouncing a check, marrying someone we don’t think is a good choice for them, quitting a job before having a new one to go to, (and so on). Agencies have the responsibility to support people in all aspects of their life with all its messiness.
•	
Expect that conversations and decisions around rights and responsibilities are real.
•	Adults do not have to prove themselves before they have the right to exercise most rights. There are no “competency” requirements for marrying, managing your own money, living on your own, or most other things. Many people may need support to accomplish those things, but they do not have to prove anything.
•	Any requirements that include “meeting this goal or that goal before you can …” must be seriously reconsidered. The questions that accompany that consideration include: Is the Agency or team or guardian expecting more from this person than other citizens and are their rights being restricted?
•	Support people to gain skills in accomplishing those things that do require competency requirements. Obtaining a driver’s license requires that all citizens meet certain criteria and pass certain tests. Many jobs require mastering a set of skills. The Agency should work creatively to support the person to learn those skills necessary to meet their dreams before rejecting the idea as being “unrealistic”. People have the right to try those things and fail.
•	Assure that whenever a person expresses dissatisfaction (verbally or behaviorally) with anything (where they live, where they work, how they socialize, who they live with, what progress they have made toward reaching their dreams) the people supporting that person raise questions about rights. Are any rights being violated at this time? If the person did not have a disability, how might they handle their dissatisfaction? What supports might be available to them in this situation? How can the organization support this person to use those supports?
•	Rights and responsibilities are complex and often changing. Assure that Agency members take these issues seriously and have the time and resources to understand them fully.

Provide access to legal counsel or advocacy whenever a person faces due process.
•	People have the right to legal counsel or advocacy at every court hearing, at every human rights committee meeting, and at any other legal proceeding.
•	Legal counsel or advocacy can be found through the Protection and Advocacy system, through the local Legal Aid office, by requesting pro bono (for free) work from a local law office, or through the local or state Arc chapter.

Information for these policies was borrowed from CQL Quality in Practice documents: http://www.thecouncil.org/qip/qiprightsresponsibilities.pdf

Universal Declaration of Human Rights Preamble

Whereas recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world,

Whereas disregard and contempt for human rights have resulted in barbarous acts which have outraged the conscience of mankind, and the advent of a world in which human beings shall enjoy freedom of speech and belief and freedom from fear and want has been proclaimed as the highest aspiration of the common people,
Whereas it is essential, if man is not to be compelled to have recourse, as a last resort, to rebellion against tyranny and oppression, that human rights should be protected by the rule of law,

Whereas it is essential to promote the development of friendly relations between nations,

Whereas the peoples of the United Nations have in the Charter reaffirmed their faith in fundamental human rights, in the dignity and worth of the human person and in the equal rights of men and women and have determined to promote social progress and better standards of life in larger freedom,

Whereas Member States have pledged themselves to achieve, in cooperation with the United Nations, the promotion of universal respect for and observance of human rights and fundamental freedoms,

Whereas a common understanding of these rights and freedoms is of the greatest importance for the full realization of this pledge,

Now, therefore,

The General Assembly,

Proclaims this Universal Declaration of Human Rights as a common standard of achievement for all peoples and all nations, to the end that every individual and every organ of society, keeping this Declaration constantly in mind, shall strive by teaching and education to promote respect for these rights and freedoms and by progressive measures, national and international, to secure their universal and effective recognition and observance, both among the peoples of Member States themselves and among the peoples of territories under their jurisdiction.

Article 1

All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.

Article 2

Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, color, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.

Furthermore, no distinction shall be made on the basis of the political, jurisdictional or international status of the country or territory to which a person belongs, whether it be independent, trust, non-self-governing or under any other limitation of sovereignty.

Article 3
Everyone has the right to life, liberty and security of person.	 
Article 4
No one shall be held in slavery or servitude; slavery and the slave trade shall be prohibited in all their forms.
Article 5
No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment.
Article 6
Everyone has the right to recognition everywhere as a person before the law.
Article 7
All are equal before the law and are entitled without any discrimination to equal protection of the law. All are entitled to equal protection against any discrimination in violation of this Declaration and against any incitement to such discrimination.
Article 8
Everyone has the right to an effective remedy by the competent national tribunals for acts violating the fundamental rights granted him by the constitution or by law.
Article 9
No one shall be subjected to arbitrary arrest, detention or exile.
Article 10
Everyone is entitled in full equality to a fair and public hearing by an independent and impartial tribunal, in the determination of his rights and obligations and of any criminal charge against him.
Article 11
Everyone charged with a penal offence has the right to be presumed innocent until proved guilty according to law in a public trial at which he has had all the guarantees necessary for his defense.
No one shall be held guilty of any penal offence on account of any act or omission which did not constitute a penal offence, under national or international law, at the
time when it was committed. Nor shall a heavier penalty be imposed than the one that was applicable at the time the penal offence was committed.

Article 12

No one shall be subjected to arbitrary interference with his privacy, family, home or correspondence, nor to attacks upon his honor and reputation. Everyone has the right to the protection of the law against such interference or attacks.

Article 13

Everyone has the right to freedom of movement and residence within the borders of each State.
Everyone has the right to leave any country, including his own, and to return to his country.

Article 14

Everyone has the right to seek and to enjoy in other countries asylum from persecution.
This right may not be invoked in the case of prosecutions genuinely arising from non-political crimes or from acts contrary to the purposes and principles of the United Nations.

Article 15

Everyone has the right to a nationality.
No one shall be arbitrarily deprived of his nationality nor denied the right to change his nationality.

Article 16

Men and women of full age, without any limitation due to race, nationality or religion, have the right to marry and to found a family. They are entitled to equal rights as to marriage, during marriage and at its dissolution.
Marriage shall be entered into only with the free and full consent of the intending spouses.
The family is the natural and fundamental group unit of society and is entitled to protection by society and the State.

Article 17

Everyone has the right to own property alone as well as in association with others.
No one shall be arbitrarily deprived of his property.

Article 18

Everyone has the right to freedom of thought, conscience and religion; this right includes freedom to change his religion or belief, and freedom, either alone or in community with others and in public or private, to manifest his religion or belief in teaching, practice, worship and observance.

Article 19

Everyone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference and to seek, receive and impart information and ideas through any media and regardless of frontiers.
Article 20

Everyone has the right to freedom of peaceful assembly and association.
No one may be compelled to belong to an association. 
Article 21

Everyone has the right to take part in the government of his country, directly or through freely chosen representatives.
Everyone has the right to equal access to public service in his country.
The will of the people shall be the basis of the authority of government; this will be expressed in periodic and genuine elections which shall be by universal and equal suffrage and shall be held by secret vote or by equivalent free voting procedures.

Article 22
Everyone, as a member of society, has the right to social security and is entitled to realization, through national effort and international co-operation and in accordance with the organization and resources of each State, of the economic, social and cultural rights indPCSPensable for his dignity and the free development of his personality.

Article 23
Everyone has the right to work, to free choice of employment, to just and favorable conditions of work and to protection against unemployment.
Everyone, without any discrimination, has the right to equal pay for equal work.
Everyone who works has the right to just and favorable remuneration ensuring for himself and his family an existence worthy of human dignity, and supplemented, if necessary, by other means of social protection.
Everyone has the right to form and to join trade unions for the protection of his interests.

Article 24
Everyone has the right to rest and leisure, including reasonable limitation of working hours and periodic holidays with pay.

Article 25
Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.
Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.

Article 26
Everyone has the right to education. Education shall be free, at least in the elementary and fundamental stages. Elementary education shall be compulsory. Technical and professional education shall be made generally available and higher education shall be equally accessible to all on the basis of merit.
Education shall be directed to the full development of the human personality and to the strengthening of respect for human rights and fundamental

freedoms. It shall promote understanding, tolerance and friendship among all nations, racial or religious groups, and shall further the activities of the United Nations for the maintenance of peace.
Parents have a prior right to choose the kind of education that shall be given to their children.

Article 27
Everyone has the right freely to participate in the cultural life of the community, to enjoy the arts and to share in scientific advancement and its benefits.
Everyone has the right to the protection of the moral and material interests resulting from any scientific, literary or artistic production of which he is the author.

Article 28
Everyone is entitled to a social and international order in which the rights and freedoms set forth in this Declaration can be fully realized.

Article 29
Everyone has duties to the community in which alone the free and full development of his personality is possible. In the exercise of his rights and freedoms, everyone shall be subject only to such limitations as are determined by law solely for the purpose of securing due recognition and respect for the rights and freedoms of others and of meeting the just requirements of morality, public order and the general welfare in a democratic society.
These rights and freedoms may in no case be exercised contrary to the purposes and principles of the United Nations.

Article 30
Nothing in this Declaration may be interpreted as implying for any State, group or person any right to engage in any activity or to perform any act aimed at the destruction of any of the rights and freedoms set forth herein.

http://www.unhchr.ch/udhr/lang/eng.htm

Section 7: POLICY 104 - COMMUNICATION RIGHTS
Policy:
BRS, Inc. is committed to upholding each person supported’s right to communicate, associate, and assemble with persons of their choice.
See the First Amendment.
Procedure:
The following guidelines will be followed to ensure person supported First Amendment rights. Telephone Use
Person supported shall have reasonable access to telephones. All calls will be placed by the person with due regard to privacy. Assistance will be provided upon request to operate the phone or access outside lines for long distance calls which are paid for by the person making the call. Accessibility features will comply with the Americans with Disabilities Act.
Mail
Person supported will send and receive mail unopened by support providers unless specifically requested by the person. Person supported will designate who will provide assistance in the presence of the person supported.
Visitors
Person supported may have visitors at reasonable times with private visiting areas available as requested. Community organizations, advocates, and support providers will have a reasonable opportunity to communicate with person supported.
Community Inclusion. Support will be provided to attend and participate in community activities as indicated in the Person Centered Support Plan, subject to person supported financial limitations.
Expression
Person supported have the right to express feelings, beliefs, and opinions regarding matters of concern. (See Policies: First Amendment, Respect, and Protection of Rights)
Worship
Person supported have the right to worship as they please.
Choice
An individual will have the right to communicate, associate, and assemble with
persons of their choice consistent with the Person Centered Support Plan including lifestyles, preferences, communication, and decision-making. An individual’s financial situation may limit some of their choices.
Limitations
There are some circumstances in which a person supported rights may be limited: Parent/Guardian rights regarding a minor child, court restrictions regarding rights, limited by developmental center or provider if the exercise of rights would interfere with the treatment of the individual or individuals, or with their immediate health and safety.
Limitations must be recommended by the Circle of Support and presented to the Human Rights Committee for review, approval, and recommendation of the DDA Regional Director.

Section 7: POLICY 105 - HUMAN RIGHTS COMMITTEE
Purpose:
To promote, safeguard, and protect the dignity, legal rights, and liberties of individuals receiving services, ensuring that their rights are respected and upheld through a comprehensive Human Rights Committee (HRC/REM) Reportable Event Management (REM) process. Note: REM and HRC/REM are synonymous and used interchangeably in this policy.
Policy:
1.	Human Rights Committee (HRC/REM) Composition and Responsibilities:
The COS will review and approval all restrictions first.
o	The HRC/REM staff to ensure balanced representation. The person served will be represented in the  COS meeting where decisions are made about restrictions and may also attend the HRC/REM.
o	The HRC/REM will review restrictive procedures, behavioral plans, and other interventions to safeguard individual rights.
o	Meetings will be held quarterly, with additional meetings as needed.
o	IF there is a disagreement with any restriction from the person serviced or their advocates, the restriction will go to the Regional HRC/REM. 
2.	Reportable Event Management (REM):
o	Implement a system for reporting, tracking, and addressing reportable events to protect individuals' rights.
o	Ensure timely reporting of incidents and appropriate follow-up actions.
3.	Review and Approval Process:
o	The HRC/REM will review all relevant policies and procedures to ensure compliance with state and federal regulations.
o	Policies will be updated annually or as needed to reflect changes in regulations or best practices.
4.	Training and Education:
o	Provide regular training for all staff on human rights and REM processes.
o	Ensure that staff understand their roles and responsibilities in protecting individuals' rights.
Procedures:
1.	Incident Reporting:
o	All staff must report any incident that may infringe on an individual's rights immediately to the HRC/REM.
o	Detailed documentation of the incident must be maintained and reviewed by the HRC/REM.
2.	HRC/REM Meetings:
o	Meetings will be documented with minutes and action items.
o	Decisions and recommendations made by the HRC/REM will be communicated to relevant staff and implemented promptly.
3.	Follow-up and Monitoring:
o	The HRC/REM will monitor the implementation of corrective actions and ensure compliance.
o	Regular audits will be conducted to ensure the ongoing protection of individuals' rights.
4.	Communication:
o	Maintain open communication channels between the HRC/REM, staff, individuals receiving services, and their families.
Consent and Emergency Procedures:
1.	Consent for Emergency Restrictions:
o	Verbal consent must be sought within one day for emergency restrictions, followed by written consent within five days.
o	Document verbal consent with a note, preferably on the same form used for written consent, with two witnesses attesting to the verbal consent.
o	Ensure all information is provided to the person giving consent, whether verbal or written.
2.	Psychotropic Medication Changes:
o	Verbal consent for changes in psychotropic medication can be obtained with the same requirements as emergency restrictions.
o	Written consent should be obtained as soon as possible.
3.	Handling Psychosis and Emergency Medication:
o	If an individual is at risk of harm and cannot consent due to psychosis, they should be referred for emergency evaluation or psychiatric hospitalization.
o	Involuntary treatments are not permitted in HCBS Waiver settings.
4.	Doctor’s Order Restrictions:
o	The Circle of Support (COS) reviews doctor’s order restrictions. If there's disagreement within the COS, the restriction is referred to the HRC/REM.
o	Informed consent must be obtained before implementing any restriction.
5.	Medication Review Process:
o	The agency's Reportable Event Management committee (REM) oversees psychotropic medication changes and consents.
o	Routine psychotropic medication reviews and emergency psychotropic medication use require HRC/REM review.
Documentation and Monitoring:
1.	Formal Rights Review Documentation:
o	Document each restriction with a benefit-risk analysis, justification, and fading plan.
o	Consent from the legal decision-maker and assent from the individual supported must be documented.
2.	Handling Non-Consensual Restrictions:
o	Restrictions may not be imposed without informed consent. Emergency services may be required for imminent risk situations.
o	Use other tools creatively to address concerns when consent cannot be obtained.
3.	Third-Party Presence During Consent:
o	A third party should be present during consent reviews to ensure understanding and validity.
o	Criteria for valid consent include rationality, adequate information, and absence of coercion.
4.	Assent Documentation:
o	Assent may be documented on the same form as informed consent.
5.	Monitoring and Expirations:
o	The ISC or designee tracks PCSP-related restrictions, while behavior analysts track BSP-related restrictions.
o	Synchronize annual review dates with the PCSP review.
By adhering to this policy, Buffalo River Services commits to upholding the highest standards of human rights protection and ensuring a safe, respectful, and supportive environment for all individuals receiving services.

Section 7: POLICY 106 – COMPLAINT/CONFLICT RESOLUTION
Policy:

It is the intent and desire that service related decisions concerning the specific and individual services and supports provided person supported by Buffalo River Services, Inc. will be determined mutually, cooperatively, and with the best interests of the recipient in mind. Recognizing however that such service decisions may not be viewed by all stakeholders in the same context, or that the delivery of services may not always meet the full expectations of person supported or families, the Agency uses the following complaint resolution process.

Person supported, families and/or legal guardians are afforded the opportunity to appeal any service related decision of the Buffalo River Services, Inc. within the specifics of this policy. Additionally, the same are encouraged to express, through a formal complaint process, any dissatisfaction with the delivery of services and/or supports. The Agency will provide a copy of this policy (#106) and procedure to all current persons supported, and include it as part of the intake material for future person supported.

Anyone wishing to file a formal complaint with someone other than the staff member, Program Director, or designee, please contact Buffalo River Services, Inc. Complaint Resolution Coordinator:
Title: Complaint Resolution Coordinator/Executive Administrative Assistant
Address: P.O. Box 847, Waynesboro, TN 38485
Phone Number: (931) 722-5401

Procedure:
1.	Any staff person may register a complaint from a person supported, authorized family member, or legal conservators of person supported.
2.	Upon admission, each person, family members and/or legal representative will be notified of the Agency Compliant Resolution Policy.
3.	Filing a complaint does not void a person’s right to request a fair hearing, nor is it a prerequisite for a fair hearing.
4.	Each staff member of the Agency will be instructed in the proper methods and procedures for registering and documenting complaints.
5.	While any staff, direct support, management, or administration may receive and register a complaint; direct support staff are encouraged to attempt referral to management of administrative staff in order to not detract from direct support responsibilities. However, if the complainant wishes to register the complaint with the direct support staff, they may do so.
6.	Upon receiving a complaint in person, by phone, letter, email, fax, or other communication device, the Complaint Resolution Coordinator, will document the complaint on the Complaint Form in its entirety with available information. The Incident Management Coordinator is provided the information so that it is tracked in the Incident Management Meeting Minutes until resolution occurs.
7.	The Complaint Resolution Coordinator assigns a complaint number to the complaint and tracks it on an internal complaint log. This is kept in the administrative office by the Complaint Resolution Coordinator.

Resolution:
•	If the complaint has a specifically identified BRS, Inc. Department or Team, and the complaint is not specifically in regard to the Department Administrator, the Department Administrator shall be responsible for attempting resolution of the complaint.
•	If the complaint is specific to the Department Administrator, the Chief Executive Officer shall acquire the responsibility for the resolution of the complaint.
•	Under the resolution section of the Complaint Form, all contacts and actions regarding resolution will be documented.
•	Contact is required by the responsible BRS, Inc. administrator to the complainant to acknowledge receipt of the complaint within 24 hours. The filing of the original complaint may suffice for this requirement (if the complaint was made directly with the administrator).
•	All complaints should have attempted resolution within 3 working days of the assignment by the Complaint Resolution Coordinator.
•	When the administrator believes the complaint has been resolved to the satisfaction of the complainant, the “Resolution Section” of the Complaint Form will be completed, and the form returned to the Complaint Resolution Coordinator.

Advanced Conflict Resolution/Appeals:

•	If after 7 working days, the administrator is unable to resolve a complaint, or the complainant is not satisfied with the proposed solution, The Complaints Resolution Coordinator shall refer the issue on to the Chief Executive Officer for review and attempt at resolution.
•	If the Chief Executive Officer is unable to resolve the complaint, the Regional Office Complaint Resolution Coordinator may be contacted before, during or after 14 work days since the filing of the complaint, regarding advice, assistance, or intervention to assist in resolving the complaint.
•	The Chief Executive Officer may also contact a mediation firm if it appears a viable and reasonable option.
NOTE: Any complaints or other issues relative to the provision of services as specified in Title 33 (TCA 33-2-602) or Title VI will be addressed according to this policy.

Section 7: POLICY 107 - SEXUALITY
Policy:
People with intellectual and developmental disabilities1, like all people, have inherent sexual rights and basic human needs. These rights and needs must be affirmed, defended, and respected.
Issue:

For years, people with intellectual and developmental disabilities have been thought to be asexual, having no need for loving, and fulfilling relationships with others.
Individual’s rights to sexuality, which is essential to human health and well-being, have been denied. This loss has affected them broadly in gender identity, friendships, self-esteem, body image and awareness, emotional growth, and social behavior. At the same time, forced participation in sexual activity is an issue for people with intellectual disabilities. Because they are considered asexual, persons supported frequently lack access to appropriate sex education in schools and as adults to training in parenting and child-rearing.

Moreover, the general public maintains other out-of-date views of the sexuality of people with intellectual and developmental disabilities. Most people have an unfounded fear that parents with intellectual disabilities cannot rear or financially support their children and thus will require more government support, including placement of children in the foster care system.

Position:

Every person has the right to exercise choices regarding sexual expression and social relationships. The presence of intellectual and developmental disabilities,

regardless of severity, does not, in itself, justify loss of rights related to sexuality. All people have the right within interpersonal relationships to:

•	Develop friendships and emotional relationships where they can love and be loved and start and stop the relationships as they choose.
•	Dignity and respect.
•	Privacy, confidentiality, and freedom of association. With respect to sexuality, persons supported have a right to:
•	Sexual expression, reflective of age, social development, cultural values, and social responsibility.
•	Information to allow informed decisions, including sex education about such issues as safe sexual practices, sexual orientation, sexual abuse, and sexually transmitted diseases.
•	Protection from sexual harassment as well as from physical, sexual, and emotional abuse and sexual relationships with paid staff.

With respect to the potential for having and rearing children, they have the right to:

•	Choices related to birth control, including the decision to have and raise children, with supports if necessary; to accept personal responsibility for these decisions; and to have control over their own bodies.
•	Have, on an individual basis, access to proper supports to assist them in rearing their children.
•	Choose for themselves whether or not to be sterilized, regardless of the severity of disability.

Procedure:
The Circle of Support, under the oversight of the DDA guidelines, will address individual needs including education as specific to the person. Each person will have educational opportunities made available to him or her by their Circle of Support. This may be in the form of individual or group counseling or teaching by a qualified instructor. A qualified instructor could be a Mental Health Counselor, a member of Planned Parenthood, or any other individual having some certification recognized by the Circle of Support as appropriate.

Section 7: POLICY 108 – NATURAL SUPPORTS

Policy:
People are satisfied with the extent and frequency of contact with their natural support networks. Natural supports are family members and close (constant, stable, steady, long- lasing, and established) friends of the person using services.
Buffalo River Services, Inc. embraces the following statement as guiding policy

“The belief that the judicious use of natural supports can enhance the opportunities and functional capabilities of individuals with disabilities. This belief is exemplified in the current emphasis on supported employment, supported living, and more fully integrated support systems in education. The importance of accessing and using support networks which are inherent in the environment is that they hold the promise of providing a more efficient and on-going basis for enabling a person with disabilities to experience a higher quality of life through increased productivity, community integration, and job satisfaction. Additionally, by identifying networks and accessing those naturally occurring supports within those networks, habilitation services will move toward a more inclusive and integrated outcome for people with disabilities.”
* Enhancing the Use of Natural Supports for People with Severe Disabilities Enhancing the Use of Natural Supports for People with Severe Disabilities, April, 1993, by, The Training and Research Institute for People with Disabilities (UAP) in conjunction with The Developmental Evaluation Center, a University Affiliated Program of the Children's Hospital, 300 Longwood Ave., Boston, MA. 02115

Procedure:
Natural supports are not paid by DDA or the Agency. The Agency will supply information and skills training as necessary to provide safe and effective natural supports. The information and training may be based on the time the time spent together. The Agency will maintain documentation of training completed by the natural support. Documentation will include the name of the natural support, the name of the person or entity providing the training, a brief description or explanation of the training provided and the date the training was provided. Consent will be obtained from the person served or their legal representative in writing before any personal information is shared. The Agency will not allow or require natural supports or volunteers to administer medication to supplant appropriately trained staff.

Section 7: POLICY 109 – VOLUNTEERS
Policy:
The Agency will provide appropriate information and skills training to volunteers as necessary to protect the health and safety of the person served and the volunteer. Procedure:
Volunteers are persons who choose to perform a service for or to support a person receiving services. The Agency will provide volunteers with Information and Training Specific to the Person. A volunteer will not be left alone with a person served or assigned responsibility to perform the duties of a trained and paid staff. Consent must be obtained from the person served or their legal representative before any personal information is shared.

Section 7: POLICY 110 – TITLE VI
Policy:
Title VI of the Civil Rights Act of 1964 prohibits certain types of discrimination in programs that utilize federal funds. DDA as well as DDA providers must comply with Title VI requirements. The Agency will not exclude, deny benefits to or otherwise discriminate against any applicant for services or person supported based on race, color or national origin in the admission to or participation in any of its programs and activities.

Procedure:
Prohibited practices include, but are not limited to, the following:
1.	Denying any service, opportunity or other benefit for which an applicant or person supported is otherwise qualified.
2.	Providing any applicant or person supported with any service or other benefit which is different or is provided in a different manner from that which is provided to others in the same program.
3.	Subjecting any person supported to segregated or separate treatment in any manner related to the receipt of a service.
4.	Restricting any person supported in any way in the enjoyment of services, facilities or any other advantage, privilege or benefit provided to others in the same program.
5.	Adopting methods of administration that would limit participation or subject any group of applicants or persons supported to discrimination.
6.	Addressing an applicant or person supported in a manner that denotes inferiority because of race, color, or national origin.
7.	Subjecting any applicant or person supported to racial or ethnic harassment, to a hostile racial or ethnic environment or to a dPCSProportionate burden of environmental health risks.
8.	Denying a person supported (or person who has been previously deprived of the opportunity) eligibility to participate as a member of a planning or advisory body which is an integral part of the program.
The Agency will ensure that applicants and persons supported receive equal treatment, equal access, equal rights and equal opportunities without regard to race, color, national origin or limited English proficiency (LEP). The Agency will meet the following requirements:
1.	The Agency will document that persons receiving services are informed of Title VI protections and remedies for Title VI violations on an annual basis. This documentation must be filed in the record for the person supported and available
1.	
for inspection.
2.	The Agency will designate a Title VI Local Coordinator.
3.	The Agency will ensure that persons supported are informed of who the Local Coordinator is and how to contact him/her.
4.	The agency has HR policies and procedures addressing:
a.	Employee training to ensure Title VI compliance during service provision.
b.	Employee training to ensure recognition of and appropriate response to Title VI violations.
c.	Complaint procedures and appeal rights pertaining to alleged Title VI violations for persons supported.
d.	Personnel practices governing responses to employees who do not maintain Title VI compliance in interacting with persons supported.
5.	The Agency will have a mechanism for advising persons regarding the options for filing a Title VI complaint.
6.	The Agency will dPCSPlay Title VI materials in conspicuous places accessible to persons.
7.	The Agency will ensure that housing decisions and transfers are made without regard to race, color, or national origin.
8.	The Agency will complete and submit an annual Title VI self-survey in the format designated by DDA and in accordance with Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition against National Origin Discrimination Affecting Limited English Proficient Persons (“Revised HHS LEP Guidance”).
9.	The Agency will orient employees to their Title VI responsibilities and the penalties for noncompliance.
10.	The Agency will ensure that vendors, subcontractors and other contracted entities are clearly informed of Title VI responsibilities and maintain Title VI compliance.
11.	Complaints filed involving funding by TDOT will be forwarded to that agency for investigation and resolution.
a.	The complaint must be filed within 180 calendar days of the alleged occurrence or when the alleged discrimination became known to the complainant.
b.	The allegation (s) must involve a covered basis such as race, color, national origin.
c.	The allegation (s) must involve a program or activity of a Federal-aid recipient, sub-recipient, or contractor.
d.	The sub-recipient final investigation report and a copy of the complaint will be forwarded to the appropriate State and Federal Agency and affected parties with 60 calendar days of the acceptance of the complaint.
a.	
Section 7: POLICY 111 – LIMITED ENGLISH PROFICIENCY POLICY
Policy:
The Agency will provide meaningful access to services to LEP persons.
Procedure:
It is the general policy of Buffalo River Services, Inc. staff not to discriminate against anyone with Limited English Proficiency (LEP), who participates in our programs and/or services. We have taken steps to ensure that all persons will be able to communicate, either through written or oral language services, with all members of our staff. These steps are as follows:

1)	Employees will have access to “I speak” cards.
2)	Once language proficiency is determined, employees will have resources available to assist the person in determining his/her need.
3)	If the need is not urgent or life threatening, employees will defer to their supervisors what steps need to be taken. The steps are, but not limited to the following:
a)	If the need is documented, the supervisor will have the document translated as soon as possible, without jeopardizing his/her duties as a supervisor.
b)	If the need is oral language services, the supervisor will take appropriate actions to provide the assistance as soon as possible through a translation service, without jeopardizing his/her duties as a supervisor.
c)	The supervisor has the obligation to the safety of his/her employees as well as to the persons supported by Buffalo River Services, Inc. to assist the need of all persons. This includes not leaving his/her work place unless it is an emergency.

4)	If the need is urgent or life threatening, employees will use, to the best of their ability, any resource available to accommodate the person.
Any person who thinks there has been discrimination against him/her because of LEP should contact the agency’s Title VI coordinator/Executive Administrative Assistant at (931) 722-5401.

Section 7: POLICY 112 – CONSERVATOR/POWER OF ATTORNEY/SUPPORTIVE DECISION MAKING

Many individuals supported by Buffalo River Services, Inc. have court appointed conservators or other legal representation. There are a variety of ways to provide assistance to an adult with I/DD, including, but not limited to, representative payee, durable power of attorney, conservatorship, limited conservatorship, health surrogate, supported decision making and others.
Conservatorship is one of the most restrictive actions taken to protect a vulnerable
person. Conservatorship involves going to court to legally remove a person’s rights in areas such as where they live, medical and financial decisions. Each court order is specific to the rights that have been removed from that particular individual.
Buffalo River Services, Inc. believes everyone has a right to make choices regardless of their legal status. Supported decision-making is an alternative to conservatorship.
Supported Decision-Making is a method of developing decision-making skills by relying on a team of trusted individuals (“Supporters”) to assist the person in collecting information, processing information, and coming to an informed decision. Buffalo River Services, Inc. is committed to supporting people and their family and/or conservators to learn more about Supported Decision-Making as a means of providing a trusted and formalized environment for people to receive assistance with decision-making while still promoting self- determination.
Buffalo River Services, Inc. will advocate for people retaining rights, particularly those not addressed by the court order, through education with individuals served, families and conservators.
While Buffalo River Services, Inc. is dedicated to maintaining harmonious working relationships with family, conservators and friends of the individual, primary focus and concern will always be a person -centered focus that supports people to exercise choices, rights and responsibilities.
In all circumstances, including when conservatorship has been established, the individual has the right:
•	to be treated with dignity and respect
•	to privacy and confidentiality
•	to exercise control over any aspect of life which the court hasn’t delegated to a
conservator
•	to have the conservator consider her/his wishes, preferences and opinions
•	to safe and humane living conditions in the least restrictive environment that meets her/his needs to equal treatment under the law
•	to ask the court to change, review or remove conservatorship
•	
In the interest of protecting individual rights, Buffalo River Services, Inc. will conduct an annual assessment to determine:
•	Are people supported to exercise the rights that are important to them;
•	Are people provided supports only to the extent needed;
•	Are people supported to advocate for themselves;
•	Does the person still need a conservator;
•	Is the conservator acting in the best interest of the person served;
•	Does the court order need to be modified or revoked;
•	Is the conservator limiting a person’s rights beyond the scope of the court order. When there are indications that the conservatorship is restricting a person’s ability to exercise rights, choice and independence.
•	A discussion will be held with the conservator to educate and discuss concerns.
•	If resolution is not reached a Circle of Concern, Person Centered Planning Meeting or Conflict Resolution meeting will be held.
•	If resolution is still not reached additional services such as an Advocate, Legal Aid or representation through the Disability Law and Advocacy Center may be considered.
•	When a conservator’s involvement in decision making reaches beyond the authority given to them by the court, and resolution cannot be reached through the services listed above, it may be decided that a change in providers is the most desirable outcome. Buffalo River Services, Inc. will provide positive support and assistance to assure a smooth transition.

Edited May 26, 2023

Section 7: POLICY 113 – POSITION STATEMENT ON STAKEHOLDER INVOLVEMENT
Buffalo River Services, Inc. will use the best practices as determined via research and discovery with affiliations with CQL and Arc in as many areas as possible including, rights, rights assessments, and medication administrations.

1)	It is important for the organization to listen to the stakeholders regarding important aspects of agency business. Some of these issues are listed here:
•	It is BRS, Inc.’s practice that the organization involves the people supported, families and others important to people when it develops and evaluates its policies, programs, services, and supports.
•	It is BRS, Inc.’s practice that people supported and staff participates in the staff retention process possibly utilizing focus groups. Managers need assistance in creative ways to recruit and retain new staff.
•	It is BRS, Inc.’s practice that the organization develop additional training based on input from staff and people supported and the results of data from internal and/or external data collected.
•	
•	It is BRS, Inc.’s practice the organization consider ways to include people
supported in the staff evaluation process.
•	It is expected that direct support staff participates in focus groups, especially when organizational issues that directly affect them are being determined.
In order to facilitate this listening process, a focus group approach will be utilized. This will become an advisory committee (such as Volunteer State People First) for the organization that will meet on a regular basis. The intention of the advisory committee will be to self- direct the agenda for each meeting. On occasion the meeting will be closed meetings with only the advisory group. On other occasions at the discretion of management and the advisory group members, meetings shall be open and allow for a “focus group” approach with facilitation around certain issues.
We will review member experiences and HCBS rules regularly for compliance and effectiveness and amend as necessary.
The organization has formulated a new expansive Declaration of Human Rights position statement that is summarized in a separate attachment.
It is BRS, Inc.’s practice that additional rights training be provided to people who receive supports and direct support staff. Rights will be shared in a different venue for people who receive supports such as by administering a rights survey once per year. The rights survey instrument is in a separate attachment.

The organization has developed a system that includes an annual rights assessment to ensure that people supported are educated on and understand and then exercise the rights that are most important to them as individuals. This rights assessment or survey is discussed with the person once per year and is usually concurrent with the PCSP planning process.
2)	Position on utilization of best practice methodology in medication (psychotropic and other) administration, health and wellness:
•	It is BRS, Inc.’s practice that people be provided understandable information about their medications and treatments, including the purpose, intended outcomes, side effects, or other risks and alternatives.
•	It is BRS, Inc.’s practice that people’s preferences and ability to self-administer medications and treatments be assessed at least annually.
•	It is BRS, Inc.’s practice that the organization develops policies around the frequency and type of health care and screenings in accordance with national standards of care and/or the American Medical Association.
•	It is BRS, Inc.’s practice for the organization to continue to ensure that people have access to preventative and ongoing health resources similar to those of same aged peers.
•	The organization is encouraged to review psychoactive medications through the HRC every six months.
•	It is BRS, Inc.’s practice that people and direct support staff be informed and
•	
educated about anticipated outcomes, adverse reactions, and potential side effects of medications and treatments.
•	It is BRS, Inc.’s practice that adverse reactions to medications and treatments be promptly reported and responded to in accordance with the organization’s policies and procedures.
•	While the organization reviews the use of psychoactive medications for individuals who receive Supported Living services, It is practice that the organization also investigate ways to ensure reviews are occurring for people who only receive PA or Day Services regardless of being self-administered or administered by someone else.

Persons supported will be assisted to obtain advocacy, guardianship, conservatorship, representative payee or alternative advocacy if needed or requested.

Section 7: POLICY 114 – BEST PRACTICE FOR CQL INDICATORS, MED CONSENT, ADVISORY
Buffalo River Services, Inc. will use best practice as determined via research and discovery with affiliations with CQL and Arc in as many areas as possible including, rights, rights assessments, and medication administrations.

3)	It is important for the organization to listen to the stakeholders regarding important aspects of agency business. Some of these issues are listed here:
•	It is practice that the organization involves the people supported, families and others important to people when it develops and evaluates its policies, programs, services, and supports.
•	It is practice that people supported and staff participates in the staff retention process possibly utilizing focus groups. Managers need assistance in creative ways to recruit and retain new staff.
•	It is practice that the organization develop additional training based on input from staff and people supported and the results of data from internal and/or external data collected
•	It is practice the organization consider ways to include people supported in the staff evaluation process
•	It is expected that direct support staff participates in focus groups, especially when organizational issues that directly affect them are being determined.
In order to facilitate this listening process a focus group approach will be utilized. This will become an advisory committee (such as Volunteer State People First) for the organization that will meet on a regular basis. The intention of the advisory committee will be to self- direct the agenda for each meeting. On occasion the meeting will be closed meetings with only the advisory group. On other occasions at the discretion of management and the

advisory group members, meetings shall be open and allow for a “focus group” approach
with facilitation around certain issues.
We will review member experiences and HCBS rules regularly for compliance and effectiveness and amend as necessary.
4)	The organization has formulated a new expansive Declaration of Human Rights position statement that is summarized in a separate attachment.
It is practice that additional rights training be provided to people who receive supports and direct support staff. Rights will be shared in a different venue for people who receive supports such as by administering a rights survey once per year. The rights survey instrument is in a separate attachment.
The organization has developed a system that includes an annual rights assessment to ensure that people supported are educated on and understand and then exercise the rights that are most important to them as individuals. This rights assessment or survey is discussed with the person once per year and is usually concurrent with the PCSP planning process.
5)	Position on utilization of best practice methodology in medication (psychotropic and other) administration, health and wellness:
It is practice that people be provided understandable information about their medications and treatments, including the purpose, intended outcomes, side effects, or other risks and alternatives.
It is practice that people’s preferences and ability to self-administer medications and treatments be assessed at least annually.
It is practice that the organization develops policies around the frequency and type of health care and screenings in accordance with national standards of care and/or the American Medical Association.
It is practice for the organization to continue to ensure that people have access to preventative and ongoing health resources similar to those of same aged peers.
The organization is encouraged to review psychoactive medications through the HRC every six months.
It is practice that people and direct support staff be informed and educated about anticipated outcomes, adverse reactions, and potential side effects of medications and treatments.
It is practice that adverse reactions to medications and treatments be promptly reported
and responded to in accordance with the organization’s policies and procedures.
While the organization reviews the use of psychoactive medications for individuals who receive Supported Living services, It is practice that the organization also investigate ways

to ensure reviews are occurring for people who only receive PA or Day Services regardless of being self-administered or administered by someone else.
Persons supported will be assisted to obtain advocacy, guardianship, conservatorship, representative payee or alternative advocacy if needed or requested.

Section 8: POLICY 101 - EMERGENCY PRECAUTIONS
Policy:
BRS, Inc. will recognize each person’s ability and circumstances in identifying and responding to emergency situations. Persons involved in person supported support will be provided information and/or training in the implementation of emergency identification and management processes or procedures as defined by funding sources.
Refer To:
Licensure Regulations Emergency Procedure Policy Staff Training Policy

Procedure:

Person supported will be evaluated by the ISC/CM and support service providers to determine events that constitute an emergency. Technical assistance from the ISC/CM may be required as indicated in DDA documents to develop the Emergency Intervention Plan (EIP).

The EIP will address specialized training that may be required, such as procedures, protocols, and providers of support services, including emergency medical response agencies. The EIP will also identify who is to be notified in the event of an emergency and documentation that may be required.

Emergencies that require the intervention or access to support services from outside entities will require the implementation of the incident management process.

In the event of a person supported’ death, the Agency and ISC/CM will follow procedures specific to DDA policy.

Section 8: POLICY 102 - MEDICAL EMERGENCIES

Policy:

In the event that a medical emergency, accident, injury, or illness arises with any person supported or staff of BRS, Inc. on Agency premises, it shall be the policy to acquire necessary medical treatment.

A medical emergency is any condition arising suddenly and unexpectedly, which has the risk of causing severe and/or fatal consequences (any condition calling for quick judgment and prompt action).

Procedure:
1.	Apply any first aid measures needed.

2.	Notify the Program Director and administrative staff.

3.	Review person supported file and contact the personal physician for instructions if possible.

4.	Transport person supported to the physician's office or to the emergency room of a local hospital, if condition indicates the need for medical care.

5.	Do not delay in calling 911 if there is a medical emergency that requires immediate response. Staff are trained in CPR Training and First Aid Training as to how and when to call 911 and initiate First Aid and CPR.

6.	If there is any doubt as to the person supporter’s ability to be transported safely, an ambulance shall be called at 911.

7.	Notify the parent/guardian.
8.	An incident report will be prepared by those who witnessed the accident or injury and submitted according to the Protection from Harm Policy.
9.	If emergency requires person supported hospitalization, the Program Director will notify The  Department of Disability and Aging and the Independent Support Coordinator/CM as required.

10.	Ensure the person supported information is given to medical professionals.

The staff member who first becomes aware of an emergency, accident, injury, or illness is responsible to carry out this policy.

Section 8: POLICY 103 – ACCIDENT/INJURY INVESTIGATIONS

Policy:

BRS, Inc. will ensure appropriate assessment and investigation of accidents and injuries.

Procedure:
Anytime a staff member has an accident/injury to him/herself or has a vehicle accident with an Agency vehicle, the Program Director will perform a drug test as soon as it is reported.

This accident investigation will be forwarded to the Risk Management Committee for peer review. The Risk Management Committee will make recommendations to the Guidance Team of any safety procedures that should be put in place in order to prevent accidents and or injures from occurring again.

The Program Director will conduct the accident investigation within 48 hours of the accident and or injury. A copy of the investigation will be forwarded to the Vice President of Compliance or designee and the Risk Management Committee Chairperson.

Section 8: POLICY 104 - FIRE EVACUATION DRILLS
Policy:
BRS, Inc. provides safe environments to all person supported based on individual needs consistent with regulations established by the Department of Commerce and Insurance and DDA Licensure. Efforts to comply with regulations and to provide the safest environment include monthly fire drills for all locations.

Procedure:
1.	Floor plans for evacuation routes will be posted at each location. Staff members will review these during orientation/training.

2.	Fire drills will be held monthly at varying times of the day (and night in residential settings) and under different weather conditions.

3.	Activate pull station or sound alarm.

4.	Evacuate all person supported and visitors from the building. Form a line of people and proceed out according to evacuation plan. One person will remain with each group being evacuated.

5.	Survey all rooms including bathrooms for anyone that was not evacuated. Close all windows and doors during survey. Use attendance records to determine if everyone has been evacuated.
6.	Contact fire department at 911. Provide information requested by operator.

7.	Evaluate, document, and discuss each event for any safety issues that may transpire.
1.	
8.	After it has been determined that it is safe to enter the building, all evacuees may reenter the building.
Section 8: POLICY 105 - SEVERE WEATHER PROCEDURES
Policy:

Severe weather drills will be held monthly in all Agency locations. All persons supported and staff will move on verbal command to the area of the building determined by the Civil Defense Authority to be the safest. The staff member in charge of each work area will be responsible for ensuring that all persons supported in his/her area move to the designated area.	A count will be taken and compared to the daily attendance record. Records of all severe weather drills and emergencies will be maintained on file with fire drill records in TIMAS database.
Procedure:
1.	Floor plans for evacuation to the designated “safe place” will be posted at each location. Staff will review these during orientation/training.

2.	Seek shelter inside.

3.	Stay away from windows, doors, and outside walls.
4.	Protect your head.

5.	Go to the interior part of the building. Get under something sturdy. Listen to radio or television station for weather status.
Remember: WATCH means that severe weather is expected.
WARNING means that severe weather is detected.

Section 8: POLICY 106 – DESCRIPTION OF SITE DISASTER PLANS
Policy:

Major disaster will be defined as fire, earthquake, tornado, or any other type of natural or unnatural phenomenon that will damage a building so that it cannot be safely used.

Procedure:

If in event of a major disaster to one of the day buildings, the Agency will proceed to

ask the National Guard Armory in the respective county to allow the Agency to bring persons supported to their facilities for temporary occupation until such time that a more permanent building can be found. Community organizations such as churches and civic clubs should be approached for both financial assistance and volunteer help to move the Agency back in to a normal routine as soon as possible. Temporary housing for day activities should be found that will allow for the meeting of the fire and safety codes of the  Department of Disability and Aging Licenser and the Tennessee Fire Marshall’s office.

In the event of such disaster, staff must notify the Chief Executive Officer immediately and then proceed to notify all appropriate state personnel. All procedures for fire, tornado, and other disaster drills will be followed.

If the disaster occurs at one of the residential homes, immediate shelter will be located at one of the National Guard Armory stations in the respective county or in another dually designated location as described by that county’s emergency plan. This could be a church or other public building. After the immediate crisis is over, the residents may be moved to other arranged living quarters at local hotels or other such establishments.

All salaried staff are expected to assist in disaster assessment and stabilization to any property of the Agency at any given time. Shifts will be created to minimize the risk of fatigue by staff during the stabilization process.
If needed, professional counselors will be obtained to assist consumers in the adjustment of trauma of losing their home or day building. Routines will be established as quickly as possible to help in relieving as much stress and anxiety as possible. It will be of utmost importance for the Agency to begin business as usual as soon as possible.
Volunteers will be asked to assist in the repair of buildings or structures if appropriate. Special precautions must be made to ensure that persons supported and families continue to receive services as soon as feasibly possible, preferably not to exceed five working days.

Emergency aid will be sought through local Red Cross chapters and local food and clothing donors. If appropriate, federal funding for disaster relief will be procured as soon as it is available. The Agency’s insurance agent will be contacted as soon as the Chief Executive Officer makes an assessment of the situation.

Medications that may have been lost or destroyed during the event will be replaced as soon as possible. Agency staff will locate the appropriate medical chart for each customer affective in another location that holds person supported records.
Pharmacists will be contacted with names of physicians and type of medication in order for the prescription to be refilled. This must occur within the same day before six hours pass.

DISASTER AND FIRE EVACUATION PROCEDURES
The floor plans for disaster evacuation will be posted at each facility. ADMINISTRATIVE OFFICES DISASTER PLAN
The alarm for disaster will be two short rings of the alarm. The designated person will sound the alarm. All activity will cease immediately. Person supported will file from each room in an orderly manner to the Cafeteria. All open doors will be closed. An appointed staff member will account for all person supported after they have entered the dining room. The appropriate staff will make a visual check of the center and return to the dining room. In the event of an actual disaster, the ranking staff member will be responsible for notifying authorities.
ADMINISTRATIVE OFFICES FIRE EVACUATION PLAN

The alarm for fire will be a continuous steady ring of the alarm. When the alarm sounds, all activity will cease immediately. Everyone will leave the building in an orderly manner. The appropriate staff will make a visual check of the building checking each room and closing all doors. When person supported reach the designated area (in front of the Vocational Center), all will be accounted for. In the event of an actual fire, the ranking staff member will be responsible for notifying authorities.
RESIDENTIAL AND SUPPORTIVE LIVING DISASTER PLAN

When disaster is impending, the ranking staff member will sound the alarm by the verbal statement "Disaster". All activity will cease. Person supported and staff will proceed in an orderly fashion to the main hallway designated as a safe area. The ranking staff member will contact appropriate authorities and the Chief Executive Officer as soon as possible. The ranking staff member will check and account for all personnel.

RESIDENTIAL AND SUPPORTIVE LIVING FIRE EVACUATION PLAN

When the designated alarm is sounded, all activity will cease. Everyone will quietly and orderly exit through the nearest exit. After leaving the house, all will proceed to the designated area. The ranking staff member will notify the appropriate authorities and make a visual check of the house checking each room and closing all doors and windows behind him/her. After the house has been completely checked, the ranking staff member will proceed to the staff parking area to account for everyone. Upon completing a visual accounting, the Chief Executive Officer will be contacted.

OFFICE (LEWIS COUNTY AND LAWERENCEBURG) DISASTER EVACUATION PLAN
Upon notification of any impending disaster, the highest ranking staff member at the BRS, Inc. office will advise everyone to stop work by the verbal alarm "Disaster". All people will move in an orderly manner to the designated disaster area and sit quietly against the wall. The ranking staff member will notify the Chief Executive Officer and proper authorities.

OFFICE (LEWIS COUNTY AND LAWERENCEBURG) FIRE EVACUATION PLAN

At the sound of the fire alarm, all activity will cease. Everyone will file in an orderly manner through the nearest exit. The ranking staff member in charge will make a check of the building, closing all doors behind him/her, proceed to the safe area and perform a head count. The ranking staff member in charge will notify the proper authorities and the Executive Director.

All Supported Living Disaster Evacuation and Fire Evacuation Plans are posted at each location as required.

ALL FLOOR PLANS FOR DISASTER EVACUATION AND FIRE EVACUATION ARE POSTED AT EACH FACILITY.

Section 8: POLICY 107 – DISASTER PLAN

Policy:
BRS, Inc. is dedicated to the person supported’s protection. It is important for all staff and persons supported to understand actions to be taken in the event of total, destructive, natural, and man-made disasters.

All Agency personnel and persons supported will be able to respond effectively to natural or man-made disasters.

Procedure:
Other policies explain in detail how to respond to natural disasters. This policy is intended to provide a planning and information tool for each location to respond while stressing additional concepts of terrorism, chemical and biological warfare, response measures, pandemics and shelter-in-place.

There are situations when evacuation is necessary, such as during flash floods.

When there is danger of water cutting off a location from resources in the community or when a building is in danger of being flooded, evacuation may be needed. Staff should be on guard watching for signs of water alerts and even calling Civil Defense for advice.
At other times, it is not wise to evacuate. Outlined in other policies and procedures, staff members will find specific instructions on how to respond to tornado, fire, and other emergencies that require staying in a building or storm shelter.
In case of other disasters, such as chemical, biological or nuclear, other measures must be ensued. The following guidelines are general in nature, but may be more specific for every location.

The following was adapted for our use as procedures from the American Red Cross publications. Copyright 2003, the American National Red Cross. All rights reserved.

What Shelter-in-Place Means:
One of the instructions you may be given in an emergency where hazardous materials may have been released into the atmosphere is to shelter-in-place. This is a precaution aimed to keep you safe while remaining indoors. (This is not the same thing as going to a shelter in case of a storm.) Shelter-in-place means selecting a small, interior room, with no or few windows, and taking refuge there. It does not mean sealing off your entire home or office building. If you are told to shelter-in- place, follow the instructions provided in this Fact Sheet.
Why You Might Need to Shelter-in-Place:
Chemical, biological, or radiological contaminants may be released accidentally or intentionally into the environment. Should this occur, information will be provided by local authorities on television and radio stations on how to protect you and your family. Because information will most likely be provided on television and radio, it is important to keep a TV or radio on, even during the workday. The important thing is for you to follow instructions of local authorities and know what to do if they advise you to shelter-in-place.
How to Shelter-in-Place At Home:
•	Close and lock all windows and exterior doors.
•	If you are told there is danger of explosion, close the windows shades, blinds, or curtains.
•	Turn off all fans, heating and air conditioning systems.
•	Close the fireplace damper.
•	
•	Get your family disaster supplies kit and make sure the radio is working.
•	Go to an interior room without windows that is above ground level. In the case of a chemical threat, an above-ground location is preferable because some chemicals are heavier than air and may seep into basements even if the windows are closed.
•	Bring your pets with you, and be sure to bring additional food and water supplies for them.

•	It is ideal to have a hard-wired telephone in the room you select. Call your emergency contact and have the phone available if you need to report a life- threatening condition. Cellular telephone equipment may be overwhelmed or damaged during an emergency.

•	Use duct tape and plastic sheeting (heavier than food wrap) to seal all cracks around the door and any vents into the room.

•	Keep listening to your radio or television until you are told all is safe or you are told to evacuate. Local officials may call for evacuation in specific areas at greatest risk in your community.
At Work:
•	Close the business.
•	If there are customers, persons supported, or visitors in the building, provide for their safety by asking them to stay – not leave. When authorities provide directions to shelter-in-place, they want everyone to take those steps now, where they are, and not drive or walk outdoors.

•	Unless there is an imminent threat, ask employees, customers, persons supported, and visitors to call their emergency contacts to let them know where they are and that they are safe.

•	Turn on call-forwarding or alternative telephone answering systems or services. If the business has voice mail or an automated attendant, change the recording to indicate that the business is closed, and that staff and visitors are remaining in the building until the authorities advise it is safe to leave.
•	Close and lock all windows, exterior doors, and any other openings to the outside.
•	If you are told there is danger of explosion, close the window shades, blinds, or curtains.

•	Have employees familiar with your building’s mechanical systems turn off all fans, heating and air conditioning systems. Some systems automatically provide for exchange of inside air with outside air – these systems, in particular, need to
•	
be turned off, sealed, or disabled.
•	Gather essential disaster supplies, such as nonperishable food, bottled water, battery- powered radios, first aid supplies, flashlights, batteries, duct tape, plastic sheeting, and plastic garbage bags.

•	Select interior room(s) above the ground floor, with the fewest windows or vents. The room(s) should have adequate space for everyone to be able to sit in. Avoid overcrowding by selecting several rooms if necessary. Large storage closets, utility rooms, pantries, copy and conference rooms without exterior windows will work well. Avoid selecting a room with mechanical equipment like ventilation blowers or pipes, because this equipment may not be able to be sealed from the outdoors.
•	It is ideal to have a hard-wired telephone in the room(s) you select. Call emergency contacts and have the phone available if you need to report a life- threatening condition. Cellular telephone equipment may be overwhelmed or damaged during an emergency.

•	Use duct tape and plastic sheeting (heavier than food wrap) to seal all cracks around the door(s) and any vents into the room.

•	Bring everyone into the room(s). Shut and lock the door(s).
•	Write down the names of everyone in the room and call your business’s designated emergency contact to report who is in the room with you and their affiliation with your business (employee, visitor, person supported, and anyone else).

•	Keep listening to the radio or television until you are told all is safe or you are told to evacuate. Local officials may call for evacuation in specific areas at greatest risk in your community.

In Your Vehicle:
If you are driving a vehicle and hear advice to “shelter-in-place” on the radio, take these steps:

•	If you are very close to home, your office, or a public building, go there immediately and go inside. Follow the shelter-in-place recommendations for the place you pick described above.

•	If you are unable to get to a home or building quickly and safely, then pull over to the side of the road. Stop your vehicle in the safest place possible. If it is sunny outside, it is preferable to stop under a bridge or in a shady spot, to avoid being overheated.

•	Turn off the engine. Close the windows and vents.
•	
•	If possible, seal the heating/air conditioning vents with duct tape.
•	Listen to the radio regularly for updated advice and instructions.
•	Stay where you are until you are told it is safe to get back on the road. Be aware that some roads may be closed or traffic detoured. Follow the directions of law enforcement officials.
Local officials on the scene are the best source of information for your particular situation. Following their instructions during and after emergencies regarding sheltering, food, water, and cleanup methods is your safest choice.

Remember that instructions to shelter-in-place are usually provided for durations of a few hours, not days or weeks. There is little danger that the room in which you are taking shelter will run out of oxygen and you will suffocate.
Shelter-in-Place in an Emergency:

From: “Disaster Supplies Kit” developed by the Federal Emergency Management Agency and the American Red Cross.

There are six basics you should stock for your home: water, food, first aid supplies, clothing and bedding, tools and emergency supplies, and special items. Keep the items that you would most likely need during an evacuation in an easy-to-carry container. Possible containers include a large covered trash container, a camping backpack, or a duffel bag.

Section 8: POLICY 108 - RESEARCH INFORMATION
Policy:
The Agency will not participate in research activities without the express consent of people supported and/or their guardians.

Procedure:

The Agency will inform DDA of any research.

Section 8: POLICY 109 – INTERNAL QUALITY ASSURANCE PROGRAM
Policy:
The Quality Assurance program is a first order of priority which offers BRS, Inc. the

opportunity to check progress on safety, quality of product and effectiveness of systems within the organization. The data produced will lead BRS, Inc. into improving services and products.

Procedure:
I.	BRS, Inc. will periodically check the systematic processes for the following areas:
1.	Access and Eligibility
2.	Safety and Security
3.	Individual Planning and Implementation
4.	Rights, Respect, and Dignity
5.	Health
6.	Choice and Decision-Making
7.	Relationships and Community
8.	Opportunities for Work
9.	Staff Qualifications and Training Requirements
10.	Incident Reporting
11.	Compliance with DDA Procedural Requirements
a.	Provide capable and qualified administrative authority
b.	Financial Accountability
12.	Individual Monthly Reporting
13.	Community Resources
14.	Agency Strategic Plan
A.	Monthly Review/Internal Quality Assurance Form
The DDA Quality Assurance Checklist will be utilized to track actions taken on broad areas listed above. Once per year, the Guidance Team will review to check for these variables: consistency of supports, effectiveness of supports, needed changes in types, intensity or amount of supports provided.

B.	Staff Qualifications and Training
Once per quarter, the Accounting Assistant will present and report on the areas of staff qualifications and training.

C.	Reportable Incident Form

To assure full compliance with DDA policies, all person supported issues of a serious nature are documented on DDA reportable incident form and the Incident Management Committee will review bi-weekly. The Incident Management Committee will review all new reportable incident bi-weekly and follow-up activity to determine if action should be taken. If a meeting is not held, the Chief Executive Officerand an adhoc committee will review urgent cases, if there are urgent issues to be addressed.
15.	Other Steps that are taken to implement an Internal Quality Assurance Plan:
1.	
A.	Strategic Planning
-	The organization will develop a strategic plan every year.
-	It is referred to often at board meetings and is given official review every year.
-	On occasion, it may receive official review semiannually.
-	The objectives are subject to amendment as the need arises through the Guidance Team and/or Board of Directors. The teams may initiate changes in the strategic plan by making recommendations to the Guidance Team. The Guidance Team then may recommend changes to the Board.
-	The Strategic Plan allows for checking the overall Agency progress in areas addressed:
•	Mission
•	Vision
•	Funding
•	Persons supported Community Employment
•	Persons supported Community Living
•	Persons supported Community Leisure Research and Development
B.	The Council of Quality Leadership and Outcome Measurement Standards

The Agency uses The Council of Quality Leadership and Outcome Measurement standards to measure overall Agency quality regarding persons supported satisfaction and quality of life. This is accomplished in several ways.

-	Every person supported has personal outcomes listed on the PCSP. Independent Support Coordinators document information reflective of the persons supported progress toward their particular outcome.
-	Personal outcome documentation is reviewed weekly by a Program Director or designee who checks to verify that work toward the outcome is being done. Suggestions are made that assist the Independent Support Coordinator. Care Coordinator, Support Coordinator in moving toward the completion of the outcome.
-	The Program Director makes routine weekly rendezvous with the teams as they participate in community-based services to observe first-hand the activities each person supported is involved in. Corrective actions are made and documented where needed.
-	Annually, a sample of persons supported are given the outcome measures self-assessment.
C.	Postage Paid Survey Cards/Letters

Formal feedback is requested on a quarterly basis from all parents and person supported regarding their satisfaction with the supports provided. This is done by presenting a return address postage paid card/letter that has a place for the person supported and/or his/her family member to make comments.

D.	Program Policy Manual
Program Policies are adhered to by the Agency staff and are reviewed periodically to assure the best possible guidelines for the delivery of services.
E.	Management Plan and Supervision Plan
BRS, Inc. maintains a management and supervision plan as required by DDA. These documents are maintained separately from the program policies and are located in the administrative office.

III.	Buffalo River Services, Inc Person Centered Support Plan –
Implementation Support Plan ECF Specific Policies

Purpose:
In order to effectively execute each person’s Person-Centered Support Plan (PCSP), Buffalo River Services, Inc. develops and executes an implementation strategy to provide detailed instructions for program managers and direct support professionals on how to best support each person they serve, who receives Employment and Community First (ECF) waivered supports.
Process:
1.	Once the determination is made that Buffalo River Services, Inc. will support a person on the ECF waiver, the assigned Buffalo River Services, Inc. Centered Trainer/Facilitator will work with the assigned Area Director to schedule the initial Buffalo River Services, Inc. Person-Centered planning meeting to develop a preliminary Person-Centered Description and PCSP, including initial outcomes. When possible, this should occur at least 30 days prior to transition.
2.	PCD/Implementation Support Plan (PCSP) will be submitted to Buffalo River Services, Inc. Area Director (AD) for review and approval. Approval must be provided within 5 business days of service initiation.
3.	AD submits approved Implementation Support Plan to the Buffalo River Services, Inc. QA and Compliance Coordinator and to the person’s Managed Care Organization (MCO) within 3 business days of approval.
4.	Standard and compliance coordinator will enter Implementation Support Plan into Therap as PCSP Outcomes and upload both the PCSP and the Implementation Support Plan into the Go to => Attached Files section of the person’s Therap account.
5.	Within 60 days, the person supported and the Buffalo River Services, Inc. support team will participate in the development of a full Person Centered Description and PCSP with support outcomes that:
a.	Are reflective of the person’s lifestyle, goals, and outcomes
b.	Include schedule, locations, and activities
c.	Short term and long-term objectives, goals, and outcomes
d.	Teaching and support methods
e.	How and what interval progress will be measured
f.	Risk mitigation strategies
g.	DSPs and back-up who will deliver the service
6.	Completed Implementation Support Plan (PCSP) will be submitted to Buffalo River Services, Inc. Director (AD) for review and approval. Approval must be provided within 5 business days of receipt.
1.	
7.	AD submits approved Implementation Support Plan to the Buffalo River Services, Inc. QA and Compliance Coordinator and to the person’s Managed Car Organization (MCA) within three business days of approval.
8.	Standards and compliance coordinator will enter Implementation Support Plan into Therap as PCSP Outcomes and upload the Implementation Support Plan into the Go To => Attached Files section of the person’s Therap account.
9.	Prior to service initiation, and then again after complete PCD/PCSP, assigned Buffalo River Services, Inc. Level Program Manager (PLPM) holds Needs-Specific Training meeting with the person supported and the DSP’s who will provide supports. Meeting may be held in person, by phone, or by video conference. Training for DSPs will be documented in Paycom.
10.	As new DSPs are introduced into the person’s program, prior to them working a shift, the assigned PLPM holds introductory/training meeting with the person supported and the DSPs who will provide supports. Meeting may be held in person, by phone, or by video conference. Training for DSPs will be documented in Paycom.
11.	Therap is used to document work on PCSP outcomes.
12.	Monthly, Lead Program Manager reviews Therap data to prepare a monthly provider review for each person supported on the ECF waiver.
13.	Lead Program Manager submits monthly provider review to the Standards and Compliance Coordinator for review.
14.	LPM submits provider review to the ECF Care Coordinator and Buffalo River Services, Inc. Standards and Compliance Coordinator who will upload the review into Therap Document Storage.
15.	Amended Implementation Support Plan (PCSP) will be submitted to Buffalo River Services, Inc. Area Director (AD) for review and approval. Approval must be provided within 5 business days of receipt.
16.	Amended and approved PCSP is sent to Standards and Compliance coordinator who updates the PCSP Outcomes and uploads the amended PCSP to Go To => Attached Files section of the person’s Therap account.

Domain 1. Access and Orientation for Services
1.a.1 Upon receiving confirmation that a member is in the process of selecting a provider and is considering the Agency, an Agency staff member will be available to meet with the member within four (4) business days of receiving the meeting request from the MCO or the member.
i)	The Agency will share information concerning:
(1)	The Agency’s experience providing the service, including the number of
individuals served to date;
(2)	The Agency’s approach to providing the services; and
(3)	When staff are expected to be available to provide services.
ii)	Staff will maintain a log of referral dates and initial visits and/or offers of visits.
i)	
1.a.2.	When CLS or CLS-FM is requested, the Agency will consider the members’ needs, interests, and preferences (including, geographic location, type of residence, number of housemates, etc.) in identifying residences that are offered.
i)	The member will be offered an opportunity to visit the residence and meet the
other residents of the home.
ii)	If the other residents of the home consent, this visit will occur within ten (10) business days of the referral from the MCO.
iii)		Efforts will be made to allow the member to have sufficient time and opportunity to determine compatibility with the potential housemates, including additional visits or opportunities to meet outside of the house.
1.a.3.	When a member is considering whether to select the Agency to provide supports, transportation will be available for the member to visit the Agency, a home being considered, or other location to meet in the community, if requested.
1.b. The Agency will maintain records of referrals from the MCOs:
i)	Track which referrals are accepted;
ii)	Track which referrals are refused;
iii)	Document reasons for any refusals; and
iv)	Document any steps that the Agency is taking to ensure that it will be able to accept similar referrals in the future.
v)	Quarterly meetings will be held to review the data.
1.c.1	When a new person is enrolled into service, the Agency will provide an initial orientation, including:
i)	An in-person orientation is provided within the first calendar week of service;
ii)	The orientation provides information verbally and through use of accessible written information;
iii)	The orientation addresses the following:
(1)	The individual’s rights;
(2)	How to express to the Agency any concerns they have with the Agency and/or the services delivered;
(3)	How to provide a complaint with the Agency;
(4)	The ECF member’s right to elevate concerns and/or complaints about their
services to the MCO and/or TennCare at any time, and how to do so;
(5)	How the member can give feedback (positive or negative) about their DSPs to the Agency;
(6)	How the member can request a change in the DSP assigned to them.
(1)	
iv)	The Agency will maintain in each member’s file, a form with a signature attesting s/he has received an orientation, within the required timeframes, that addresses all of the requirements listed above (1–6).

1.c.2. Prior to services beginning, the ECF Director or designee will meet with the ECF member and the DSP(s) that will support the member:
i)	To clearly define the parameters and expectations of the service(s) authorized for the person;
ii)	The specific duties of the DSP(s) and the DSPs training on the specific service(s);
iii)		If the ECF member lives with other family members, the Director or designee ensures the other family members understand the expectations regarding what is appropriate for the DSP to assist with and what is not appropriate.

Domain 2. Person Centered Support Plan Implementation and Support Delivery
2.a.	1 For Employment-Small Group, Employment Path, Community Integration Support, Independent Living Skills Training, Personal Assistance, Supportive Home Care, CLS and CLS-FM services the Agency shall:
i)	Develop an initial plan for service implementation within five (5) business days of the date services commence, including minimally schedule, locations, and activities;
ii)	If the service will continue beyond 15 hours or thirty (30) calendar days (whichever would come first, an initial plan is in place, including:
(1)	Reflective of the PCSP
(2)	Schedules, locations, and activities
iii)	If the service continues beyond 40 hours or sixty (60) calendar days (whichever would come first), a complete plan is in place within five (5) calendar days of service provision exceeding 40 hours or sixty (60) calendar days (whichever would come first), including the following:
(1)	A clearly defined schedule
(2)	Locations identified
(3)	Activities identified
(4)	Short-term objectives/outcomes
(5)	Long-term goals/outcomes
(6)	Teaching and/or support methods
(7)	How progress toward goals and outcomes will be measured and at what intervals
(8)	Risk mitigation strategies (as applicable)
(1)	
(9)	DSPs who will be involved in delivering the service(s) including primary and back up.
iv)	The Agency shall always support the participation of the member and their legal representative, if applicable, in the development of the implementation plan. If the member declines to participate in the development of the plan the reason shall be documented.
v)	The final plan for service implementation will be shared with the member, their legal representative, as applicable, and the MCO Support Coordinator within 3 business days of completion.
vi)	The Agency shall actively encourage and invite the legal representative (if applicable) and least one involved family member, friend or natural support, if desired (not opposed) by the ECF member, to participate in the development of the plan for service implementation.

2.b.	The Agency shall ensure the ECF members are aware in advance of who will be delivering the service(s) to them.
i)	The Agency shall identify DSPs (primary and back-up) assigned to deliver services to the ECF member and shall notify the member, either by including the information in the implementation plan or by telephone (for services that don’t require an implementation plan).
ii)	The Agency shall ensure that the member has the opportunity to meet a new DSP prior to the DSP beginning to provide service to the ECF member.
iii)	When a DSP, who is not listed in the implementation plan and/or has not previously worked with a member, is scheduled to provide a service, the member shall be notified in advance and has the opportunity to meet the new DSP a least one day before the DSP begins providing service to the member.

2.c.	The Agency shall ensure DSPs and other staff understand the approved definitions(s) for the service(s) being provided; and are knowledgeable about the member’s PCSP, and the plan for services implementation (if applicable), and understand how to use one (or both, if applicable) as a resource.
i)	The Agency shall provide necessary training for DSPs on service definitions prior to the DSP providing the service(s).
ii)	DSPs and other staff involved in service delivery have access to, have been trained and are knowledgeable about the contents of the PCSP
iii)	DSPs and other staff involved in service delivery have access to, have been trained and are knowledgeable about the requirements of the implementation plan for services.
iv)	Documentation of the training shall be maintained.
i)	
2.d.	Agency staff shall document the provision of services and supports in accordance with the PCSP, and the implementation plan if applicable.
i)	Agency staff shall receive training to ensure accurate and sufficient documentation of the delivery of services, consistent with each service’s stated requirements, and in accordance with the member’s PCSP and implementation plan.
ii)	Staff shall maintain complete and up-to-date documentation that reflects services are delivered consistent with each service’s stated requirements, and in accordance with the member’s PCSP and implementation plan.
iii)	The documentation of delivery of services (activities, schedules, etc.) reflects the member’s desired lifestyle, goals and outcomes as noted in the PCSP and the implementation plan.
iv)	The documentation includes:
(1)	Evidence the service was provided;
(2)	Documentation of the specific nature of the support provided by staff;
(3)	Staff notes and observations about learning and progress toward goals;
(a)	If during the process of service delivery, a discrepancy between the individual’s desires/preferences and those documented in the PCSP is identified, the Support Coordinator shall be notified;
(b)	If during the process of service delivery, a discrepancy between the individual’s desires/preferences and those documented in the plan for service implementation is identified, the Agency shall revise the plan to reflect this learning.
(4)	Identification of concerns/changes or other relevant issues about the service interval that other support staff need to know.
v)	Services are implemented according to the timeframes identified in the PCSP and implementation plan or there is documentation to support the extension of timeframe and/or the need to update this in the PCSP (and implementation plan, if applicable).
vi)	Services are consistently provided in a timely fashion, and in the approved type, amount, frequency and duration identified in the PCSP.
vii)	Discrepancies in approved units versus delivered units are identified and explained.

2.e.	The plan for service implementation shall be updated as needed including:
i)	Within five (5) business days of receiving an updated/revised PCSP if the updates/revisions are pertinent to the services being provided.
ii)	At least quarterly for services that continue on an on-going basis.
iii)	Within ten (10) business days, staff shall receive training on the updated plan.

2.f.	The plan for service implementation shall be reviewed at least quarterly for
effectiveness in achieving the member’s goals and objectives, and modified when

there is little or no progress resulting.

2.f.1	Target indicator: At least monthly, the provider’s plan for service implementation regardless of program type (DDA, ECF, Choices, Technology, Katie Beckett or MAPS) is assessed for effectiveness in achieving the individual’s goals and objectives, and is modified when there is little or no progress resulting. The provider will consult with the MCO care coordinator or ISC as appropriate for changes and edits to the PCSP. And the provider will also edit the implementation plans as required.
Policy:
Monthly, the provider’s plan for service implementation is assessed for effectiveness in achieving the individual’s goals and objectives, and the plan is modified when there is little or no progress resulting.
Process:
Identifying needed modifications to the PCSP if applicable, and notifying the MCO Support Coordinator. Implementation/Outcome.

Evidential Documentation may be required per the following among other evidences:
1.	Evidence that at least monthly the provider’s plan for service implementation and the other supporting plans are assessed for effectiveness in achieving the individual’s goals and objectives. If it is noted that there is no progress resulting from current outcomes, the plan should be considered for modification.
2.	Evidence that the MCO Support Coordinator is notified if the provider identifies the need for modifications to the PCSP can be documented in email, case notes or daily documentation, or other types of evidence. Evidence should be reflected in the individual’s plan for service implementation and daily notes.

Domain 3. Choice and Decision Making
3.a.	The Agency is committed to supporting self-determination, informed choice/decision-making.
i)	The Agency shall utilize principles and practices of supported decision-making as part of ensuring this commitment.
ii)	DSPs shall receive training on the concepts of self-determination, informed decision/choice making, and supported decision-making principles and practices, including the reasons why service providers need to facilitate self-determination and informed decision/choice making by the individuals they support.
iii)	DSP knowledge and practice of these concepts shall be ensured through supervision practices and performance evaluation strategies.
iv)	In providing supports, DSPs shall facilitate these principles by:
(1)	Encouraging the individual to be comfortable expressing choices or opinions,
(1)	
(2)	Providing unbiased information and experiences to facilitate informed decision and choices, and
(3)	Ensuring that there is no criticism, disapproval or retaliation for opinions, choices and decisions expressed.
v)	Agency staff shall support family members, friends, and/or other natural supports to encourage self-determination and informed decision-making and choice with the individuals that they support.
vi)	Agency staff shall support family members, friends, and/or other natural supports through sharing, educating, and encouraging them to utilize supported decision-making strategies.
vii)	Individuals shall receive accurate and accessible information about how to learn more about self-advocacy and supported decision-making and during the orientation. The member (and legal representative, if applicable) will be asked to sign a form attesting to the fact that this information was presented during their orientation.

3.b.	The Agency shall solicit, document and address feedback from individuals supported regarding individual experience and satisfaction with the supports provided.
i)	The Agency shall solicit input from individuals, legal representatives, if applicable, and involved family members, friends, and natural supports. The member and relevant others shall be informed of this process at orientation and ongoing on an annual basis.
ii)	Agency management shall attempt to resolve concerns, answer questions and respond to suggestions or requests within three (3) business days of receiving such.
iii)	The Agency shall consider and implement suggestions or recommendations from the member and/or family if feasible. If the suggestions or recommendations are not feasible, then the member and/or family shall be so informed. The appropriate MCO and/or TennCare may also be informed as applicable.
i.	At least annually, the Agency shall:
1.	Review the feedback received during the year;
2.	Aggregate, trend and formally analyze the data on the feedback received during the year;
3.	Use the analysis of aggregated data in the Agency’s
organizational quality improvement efforts

3.c.	The Agency shall implement a formal process to address complaints from members or their representatives.
i)	If a member or the member’s family or legal representative has a complaint or concern about the quality of support, about a particular staff, or feels that his/her rights have been violated, the member or someone acting on his/her behalf may call
i)	
or visit the Vice President of Compliance or Chief Executive Officer to discuss the issue(s).
ii)	Once the administrator receives the complaint or concern, it will be investigated and a decision made as to how the issue can be resolved. The investigation into the matter shall commence within five (5) business days of receipt and shall be resolved within thirty (30) calendar days. If the member is not satisfied with the results of the Agency action, he/she may file a complaint with the appropriate MCO.
iii)	The Agency shall maintain a written complaint log that includes any actions taken in response to the complaint. The log will be available for the MCO to review.
iv)	If the member or representative prefers to file a complaint directly with the MCO, information shall be provided for them to do so.
v)	At least annually, the Agency shall:
(1)	Review the formal complaints received during the year;
(2)	Aggregate, trend and formally analyze the data on complaints received during the year;
(3)	Use the analysis of aggregated data in the Agency’s organizational quality
improvement efforts.

Domain 4. Opportunities for Integrated Work
4.a.	The Agency shall track the work status for each ECF member. At least every six months the status will be updated. Work status will be tracked using the following categories:
i)	Number and percentage or individuals working in individualized employment in integrated, community setting that pays at least minimum wage;
ii)	Number and percentage or individuals working but not in individualized employment in integrated, community setting that pays at least minimum wage;
iii)	Number and percentage or individuals not working in individualized employment in integrated, community setting or small group employment – but are of working age (18-62);
iv)	Number and percentage of individuals at retirement age (63 or older) who have chosen not to work.
v)	Of the individuals who are not working in and individualized, integrated, community setting making at least minimum wage:
(1)	Number and percentage of individuals that have a goal (in PCSP) to obtain individualized employment;
(2)	Number and percentage of individuals pursuing individualized employment from some other source;
(3)	Number and percentage of individuals that do not have a goal in (PCSP) to obtain individualized employment.
(1)	
4.b.	The Agency embraces and employs an “Employment First” philosophy and as such
shall:
i)	Encourage and support ECF members to either pursue or maintain work in integrated individualized employment or self-employment.
ii)	Provide an orientation and semi-annual training to DSPs on the philosophy and principles of Employment First focused on building the knowledge, skills and attitudes necessary to understand, embrace and implement Employment First principles and practices with members they support.
iii)	DSPs will understand how the service they are providing can be used to effectively encourage and support individuals to either pursue or maintain work.

4.c.	When an ECF member (who does not have an employment goal in his/her PCSP) expresses an interest in pursuing employment, the Agency shall notify the MCO Support Coordinator within five (5) business days so the member can be connected to sources of employment service.

4.d.	The Agency shall implement a quality improvement process that involves annually reviewing the date described in 4.a. (above) and implement strategies for sustaining, and improving the number and percentage of ECF members served that are working in individualized integrated employment or self-employment.

Domain 5. Relationships and Community Membership.
5.a.	The Agency shall research, identify, and map opportunities for community involvement, participation and membership for ECF members supported.
i)	Efforts will be focused on community clubs, organizations or groups that the member chooses.
ii)	Efforts will focus on opportunities within the geographic area in which the member lives or works or otherwise can access.
iii)	If members are unsure of their interests, staff will support them to actively explore a variety of community experiences to assist in identifying their interests.
iv)	Staff will share the results of the research efforts with the member and other people involved in supporting the member.

5.b.	The Agency shall support members to be actively involved in the community, in ways that reflect their interests, preferences and goals.
1.a.	
i)	Staff will be trained to ensure that they facilitate personalized opportunities for each member.
ii)	Members shall be supported to be actively engaged in community activities and to fill valued social roles that reflect his/her interests, preferences and goals.

5.c.	The Agency shall facilitate and support members to develop and maintain positive relationships with other members of the community.
i)	The Agency will support members to visit friends, acquaintances, and family.
ii)	The Agency will support members to visit places where new friends and/or acquaintances might be developed on a frequent basis.
iii)	Agency staff will attempt to identify promising acquaintance relationships for the member and implement specific supports to create opportunities to evolve into more meaningful and on-going relationships.

5.d.	The Agency shall support members to maintain existing relationships.
i)	DSPs will identify existing meaningful relationships for each individual they support;
ii)	Agency staff shall build opportunities for the individual to maintain those relationships into the provision of services and supports, including the implementation plan.

5.e.	The Agency shall actively fade out paid supports as possible, including:
i)	Identification of fading opportunities on a at least a semi-annual basis;
ii)	Consideration of all strategies for fading in identifying fading opportunities and developing fading plans, including:
(1)	Systematic instruction or other training for independence to reduce the need for paid staff support;
(2)	Facilitating interdependence to reduce the need for paid staff support (i.e., ability to rely on natural supports for support needed or to rely on other individuals receiving ECF services also present, such as peer support, at home or in community with the individual); and
(3)	Using technology/adaptive aids to reduce the need for paid staff support.
iii)	Evaluation of opportunities in relation to potential risks, and development of risk mitigation strategies as needed;
iv)	Development of fading plans to take advantage of opportunities identified, including incorporation of risk mitigation strategies as needed and back-up plan to restore paid supports in and when necessary;
i)	
v)	Informing necessary parties, before implementing fading plan, and getting necessary agreements;
vi)	Implementing the fading plan;
vii)	Monitoring the natural relationships that replaced or reduce the need for paid supports and re-evaluating for continued appropriateness;
viii)	Provisions to revise a fading plan that was not successful or only partially successful; and
ix)	Consultation with the MCO Support Coordinator to adjust paid services accordingly.

5.f.	Agency staff shall receive training and shall be knowledgeable about the concept of fading supports.

Domain 6. Rights, Respect, Dignity
6.a.	The Agency shall treat all ECF members with dignity and respect, including:
i)	Staff recognize their role as empowering support, rather than as a caretaker or an authority figure;
ii)	Identifying each individual’s unique gifts and capacities and designing/delivering services that enable individuals to share and capitalize upon those gifts and capacities to the greatest extent possible;
iii)	Recognizing each individual as someone with inherent worth and value;
iv)	Establishing a culture of respect by:
(1)	Addressing the member in a way that is age appropriate;
(2)	Treating adults as competent adults (this includes but is not limited to honoring all aright/freedoms retained if legal representative is involved);
(3)	Respecting the member as a primary stakeholder of the Agency (responding timely and courteously at all times)
(4)	Recognizing and showing appreciation for each individual’s unique gifts and
capacities;
(5)	Maintaining and operating from a firm belief that every individual can, with positive and effective supports as needed:
(a)	Work in individual integrated employment or self-employment; and
(b)	Develop a circle of natural supports (e.g., family, friend, co-workers) that truly care about, like and appreciate their relationship with the individual.

6.b.	1 The Agency shall support members to exercise their fundamental rights and have as much control over their lives as possible, including supporting any member:
i)	Recognizing and supporting each individual’s rights as a citizen;
i)	
ii)	Ensuring DSPs are trained on and understand the rights individuals have as citizens;
iii)	Ensuring individuals who retain the right to vote are provided support to vote;
iv)	Ensuring individuals are not denied support to participate in a protest or political rally, join a self- advocacy group or other type of social/political action group, actively participate in their chosen religion, and take full advantage of their rights to equal opportunity and equal protection under the law;
v)	confirmation that information is not released without current consent signed by the individual and/or legal representative, if appropriate; and
vi)	Providing individuals and /or legal representatives, if applicable, with understandable information regarding their rights as citizens, and other rights, including:
(1)	The Agency’s grievance and appeal rights;
(2)	Rights to confidentiality;
(3)	Rights to access records; and
(4)	Rights to decide with whom to share information.
vii)	For people in CLS and CLS-FM:
(1)	The Agency shall not restrict when individuals may be present in their home, as long as individuals have the support they may need (regardless of source), as specified in the PCSP;
(2)	Ensuring that individuals are aware that they have a legally enforceable agreement that gives them the same protections as a lease, and that the document is made accessible to them.

6.b.2 The Agency appropriately involves legal representative, if applicable, in accordance with the scope and limits of their legally sanctioned roles, including:
i)	Obtaining and maintaining copies of relevant legal documents that confirm the role and powers (including limits on powers and legal duties/obligations) of the conservator or other legal appointed representative for each individual supported, when applicable.
ii)	Ensuring DSPs are trained on the scope/limits of the role and powers (including limits on powers and legal duties/obligations) of the conservator or other legally appointed representative before providing services and supports for an individual.
iii)	Ensuring legal representatives, if applicable, are appropriately involved in accordance with the scope and limits of their legally sanctioned roles.
iv)	Ensuring DSPs have a staff “point-of-contact” who will address conservatorship and alternatives to conservatorship, including the rights the individual retains and the duties/scope of authority of those appointed as conservators or those appointed to fill alternative roles.

6.c.	The Agency assists in management of personal funds in a manner of maximizing each
individual’s personal control over their personal funds by:

i)	The use of strategies that support individuals to:
(1)	Utilize banks and maximize control, ownership, and management of their own bank accounts;
(2)	Receive and manage their earned income through paycheck made out to the
individual or direct deposit into the individual’s own bank account;
(3)	Do necessary reporting and monitoring of income and assets in order to maintain eligibility for key benefits and programs;
(4)	Develop and follow a personal budget, reflecting personal preferences for saving, spending and the need to meet specific obligations each month;
(5)	Keep appropriate financial records in a secure place in the individual’s home
or other safe location (e.g., receipts, monthly bills, checkbook ledgers).
ii)	Providing assistance that is sufficient and appropriate for the person while not
being unnecessarily restrictive, given the person’s abilities, including;
(1)	Safeguarding personal funds at home,
(2)	Using or storing personal funds inside the home,
(3)	Carrying and using personal funds outside the home,
(4)	Conducting necessary bank transactions (e.g., deposits, withdrawals, transfers).
iii)	Seeking alternatives to Representative Payee arrangements as feasible and as desired by the individual;
iv)	Ensuring DSPs and other appropriate staff are trained on Agency policies and procedures.

6.d.	The Agency shall support people to live their lives without undue restriction.
i)	Any rights restrictions shall be imposed only in accordance with existing TennCare and MCO policy, including the HCBS Settings Rules;
ii)	The Agency shall track any restrictions in PCSPs for individuals served;
iii)	The Agency shall provide individuals and legal representatives, if applicable, with information about risks, benefits, alternatives, and ensuring they have given voluntary, documented consent for any restriction.
(1)	Consent is reviewed at least annually,
(2)	If the review indicates that the restriction is appropriate and necessary, it may be renewed.
(3)	If the review indicates that the restriction is no longer warranted, it shall be reduced or eliminated.

Domain 7. Health
7.a.	The Agency shall support individuals to pursue health and wellness goals, including those identified in their PCSP, based on personal preferences by:
i)	An Agency commitment to making wellness activities part of each individual’s
i)	
lifestyle;
ii)	Ensuring individuals have flexibility in choosing how to pursue health and wellness goals, including those goals specified in their PCSPs;
iii)	Delivering supports that reflects individual preference for how to maximize health and wellness, including:
(1)	Exercise preferences;
(2)	Preferred diet/nutrition strategies; and
(3) Preferred strategies for ensuring emotional health.
iv)	Ensuring DSPs are trained on wellness as a distinct outcome and the various ways to promote and sustain wellness for the individual(s) they support (within the first 3 months of employment).

7.b.	1. Agency staff shall monitor members’ emerging health care needs, including:
i)	Provision of healthcare monitoring, including the accurate identification and recording of new health issues and needs of the individual as perceived by staff and as identified by practitioners during health-related appointments.
ii)	Communicating pertinent information to the member’s MCO Support Coordinator in a timely manner (i.e., within 48 hours for reports not otherwise required by ECF Critical Incident Policy);
iii)	Ensuring DSPs are trained on the Agency process.

7.b.2. If the PCSP and/or the plan for service implementation indicate that the Agency is responsible for assisting the member to receive health care, then the Agency shall provide and document the necessary supports, including:
i)	Assisting the member in setting up appointments,
ii)	Assisting the member in arranging for transportation to the appointment(s),
iii)	Accompanying the member to the appointments as requested,
iv)	Documenting the results of the appointments,
v)	Assisting the member to follow up on recommendations from the appointment, as requested,
vi)	Reporting the results of the appointment to the MCO Support Coordinator and others as may be appropriate.

7.c.	The Agency implements medication practices that ensure the individual takes medication safely with a minimum of errors and omissions:
7.a.	
i)	If the Agency is identified in the PCSP as responsible for supporting the member by administering medications, including prescribed and/or over the counter, during the provision of services, the Agency does this in accordance with current physician’s orders.
ii)	If the Agency support a person who self-administers his/her medication, the Agency will maintain a list of the person’s medications.
iii)	The Agency shall implement the medication policy as approved by the  Department of Disability and Aging;
iv)	The Agency shall review its medication safety policy annually for continued accuracy and appropriateness;
v)	Only appropriately trained staff will administer medications:
(1)	All unlicensed personnel who administer medications shall have successfully completed the DDA Medication Administration for Unlicensed Personnel course;
(2)	Prior to delegation of health care tasks such as glucose monitoring, oxygen administration, wound care, et cetera, there must be documentation of the following, including:
(a)	That the RN personally is delegating his/her license;
(b)	Names of staff delegation is applicable to;
(c)	Specific task(s) being delegated;
(d)	Description of training provided to staff;
(e)	Description of how the RN will monitor staff; and
(f)	Conditions for termination of delegation (e.g., RN leaves employment).
ii)	The Agency shall implement procedures for oversight of the administration of medication and reporting of medication errors when staff are responsible for administering medications.
iii)	Medication errors shall be reviewed, trends identified and analyzed and corrective actions and recommendations are developed and implement to prevent future errors from occurring.

Domain 8. Safety and Security
8.a.1.	The Agency shall support ECF members in a manner which mitigates risks while recognizing the concept of dignity of risk, including:
i)	Recognition that the normal taking of risks in life is essential to personal growth and development;
ii)	Processes for facilitating independence and use of person-centered fading plans;
i)	
iii)	A process for implementing strategies to mitigate risks noted in the PCSP and the Agency’s plan for service implementation;
iv)	The use of a formal risk assessment tool to aid in the identification of risks;
v)	A process for including in the Agency plan of service implementation strategies to mitigate risks that have not been identified in the PCSP; and
vi)	Formalized guidance for staff that addresses how to engage conservators/parents around the benefits of planned/calculated risks for the person.

8.a.2.	The Agency shall implement training and professional development opportunities for DSPs, including Agency commitment to adopting a learning culture where reportable events and/or critical incidents occur as the result of a provider implementing services with proper attention to dignity of risk:
i)	The Agency shall ensure staff are trained in the concept of dignity of risk and how to minimize risks in ways that do not curtail individuals’ ability to grow, try new thing, and accomplish their goals;
ii)	Establish an approach that involves learning to inform future practice when a Reportable Event that is determined to a critical incident occurs.

8.b. The Agency shall implement practices for resolving emergencies and emergency health care needs in a timely manner when they arise:
i)	When a person supported suffers from a serious health care situation that is life-threatening or potentially life-threatening and requires immediate attention (e.g., serious accident, serious undiagnosed illness, recurrence of a serious diagnosed illness):
(1)		The staff present will take appropriate action to identify the specific injury or ailment;
(2)		The staff will take action to comfort the individual, including administering first aid or other emergency procedures as appropriate. If, in the opinion of the Direct Support Professional or nurse present, the person requires immediate medical attention, the staff should call for emergency assistance (911). (Provide emergency personnel with information including name, age, what is wrong, current diagnoses, allergies, and current abnormal vital signs).
(3)	After calling for emergency assistance, the staff should call their supervisor
or the Team’s on-call manager to report what has occurred.

(4)	After the person receives attention and/or is taken to the doctor or hospital, as appropriate, the staff member shall immediately notify the person’s legal representative/family, if applicable.
(5)	The MCO Support Coordinator shall be notified of any emergency within 24 hours.
(6)	Within one hour of the incident, staff must contact the Incident Management Coordinator to complete a Reportable Event Report Form (RERF), if necessary.
(7)	Other documentation shall be completed in the individual’s record as required, including notification of the family/legal representative and MCO Support Coordinator.
(8)	For all people who have been identified as having high medical and/or behavioral or mental health needs, emergency plans will be developed as follows:
(a)	Addressing what an emergency looks like for the person;
(b)	What to do in an emergency;
(c)	Who to contact in an emergency.

8.c. The Agency shall assure that all sites where supports are offered are maintained in a safe and sanitary condition.
i)	For Agency owned or Agency controlled sites where CLS supports are provided:
(1)	All CLS homes will be monitored weekly by review of electronic notes submitted by home staff.
(2)		All CLS homes will be visited by a manager each week, including weekends and holidays.
(3)		If any conditions which endanger the person(s) living in the home are detected, then the condition(s) will be immediately corrected or the person(s) will be relocated until the home is made safe again.
(4)	If other, non-threatening conditions exist, they will be corrected as quickly as possible.
(5)		If unsafe or unsanitary conditions are detected, the individuals supported and the MCO Support Coordinator shall be made aware of the situation.

ii)	For non-Agency controlled sites where supports are provided (including CLS:FM):
(1)	All sites will be visited by a manager at least twice per month;
(2)		If any conditions exist which endanger the member or the support staff, the person and/or family will be immediately contacted and asked to begin immediate restoration or change of venue for the supports.
(3)		If the health and safety concerns are not rectified in a timely manner the Support Coordinator will be contacted and informed of the situation.
(4)		If unsafe or unsanitary conditions are detected, the individuals supported and the MCO Support Coordinator shall be made aware of the situation.
iii)	Staff shall be trained on the Agency’s policy for maintaining a sanitary and safe
i)	
environment.

Domain 9. Direct Support Staff

9.a.1	The Agency shall include information regarding the ECF CHOICES , ECF services and supports, and individuals receiving ECF services during the recruitment process.
i)	Recruitment for ECF staff will be differentiated from DSP recruitment by use of
another title, “Community Facilitator”.
ii)	Recruitment correspondence shall include information about the purpose and goals of the ECF program, services and supports offered, individuals receiving those supports, and typical job duties that emphasize an empowering rather than caretaking role for staff.

9.a.2	The Agency shall have a thorough interview process.
i)	The ECF Director shall participate in all interviews for potential ECF employees.
ii)	Interviewers shall employ probes or questions designed to evaluate the applicant’s potential for supporting individuals in a respectful, empowering, and conscientious manner that balance offering opportunities for personal growth and increased independence with providing necessary supports to minimize risks.

9.b.1	The Agency shall track staff turnover of ECF employees. Including:
i)	Percentage of staff turnover for each service being provided;
ii)	Reasons for the staff turnover;
iii)	Periodic analysis of the turnover data;
iv)	Use of the data to reduce future turnover.

9.b.2	The Agency shall ensure that newly hired staff complete shadowing or routine activities with existing staff with the first 3 days of the orientation and training schedule.

9.c.	The Agency shall support members to be actively involved in the process of hiring and evaluation of the staff who provide them supports.
i)	Members (and family/legal representatives as appropriate) shall have the opportunity to meet prospective support providers prior to assignment.
ii)	If more than one prospective employee is available, then more than one
i)	
option will be presented. If more than one prospective employee is not available, then the member will have to approve or decline the staff that is available.
iii)	If prospective staff are only supporting one member, then that member shall have the final selection authority on that employee.
iv)	The ECF Director shall communicate with the member and family, as appropriate, in evaluating the effectiveness of the support staff.
1.	During the quarterly contacts, the ECF Director shall ask the member and/or family to provide information to help evaluate the performance of the staff;
2.	The ECF Director shall utilize the information in evaluating the staff’s
performance and provide feedback to the staff as necessary.
v)	If a member decides that he/she wants to make a change in the staff, a call or other contact will be made with the ECF Director. A change will be facilitated as quickly as feasible. If a change cannot be made, then the reason(s) will be documented.
9.d.	The Agency shall have sufficient qualified and trained staff; including:
i)	Staff shall receive training on how to implement ECF services, especially focusing on the services that they will be providing and the intended outcome of those services;
i)	Staff shall complete all required training prior to providing supports for ECF members;
ii)	Sufficient staff will be available to provide supports, including backup or
emergency staff with the backup staff will be identified in the plan of implementation;
iii)	Backup staff shall have the same training and qualifications as the regular staff that they are replacing.

9.e.	The Agency shall ensure that all vehicles meet the physical needs of the members and are routinely inspected and maintained, including:
i)	All vehicles used for transportation shall be inspected every three (3) months;
ii)	Any concerns identified in the inspection shall be corrected in a timely fashion;
iii)	Any identified safety issues will be corrected prior to using the vehicle to transport individuals receiving supports;
iv)	Accessible transportation shall be available for members as needed.
i)	
IV.	Buffalo River Services, Inc. Technology Plan and Policies
Commitment to Technology 
Buffalo River Services, Inc. recognizes that technology can change the way people are supported to be more independent in their lives. Buffalo River Services, Inc. is committed to exploring enabling technology for the purpose of increasing independence and self- determination as well as reducing paid supports in a person’s life. Buffalo River Services, Inc. will evaluate candidates who can benefit from technology such as sensors, mobile technology, and remote caregiving supports. Use of technology will supplement the supports already provided by the agency with a goal of allowing a person to live the life they envision for themselves.

Buffalo River Services, Inc.is committed to promoting a cultural change for the acceptance of technology through education, sharing success stories, public education, and support of technology in all aspects of agency operations.

Positive Supports and PERSON-CENTERED Principles

Buffalo River Services, Inc. adheres to person-centered principles and a model of positive behavior supports. Person Centered Planning focuses on the people and their needs by putting them in charge of defining the direction for their lives. This model is disseminated into agency culture and practice through the following processes.

The agency maintains a due date list that includes PCSP end dates. 90 days pre-PCSP a Personal Outcome Measure Interview and Annual Assessment of Rights, Supports and Protection is completed with the person and those most familiar with the person including support staff, family and natural supports. Included in this assessment is a technology assessment. Information learned during the POM and Annual Assessment of Rights, Supports and Protection is discussed with the person, at the house meeting, Incident Review Committee, and pre-PCSP Planning meeting. Supports and issues identified as important by the individual are then incorporated into the PCSP and trained on with support staff through a Training Specific to Individual at PCSP implementation.

In addition, Buffalo River Services, Inc. is committed to:
•	all DSP and management staff participating on the COS for a person supported through enabling technology, will complete 2-day Person Centered Thinking training, and a 4-day Personal Outcome Measures class;
•	DDA facilitated Personal Planning meetings with all persons supported attended by the person and those most familiar with the person in attendance;
•	PCSP meetings attended by the person, members of management, family and natural support, and DSP staff most familiar with the person;
•	
•	Regular follow up and monitoring of PCSP implementation by management to assure that person centered wishes are identified, documented, implemented, and monitored for effectiveness;
•	Identification in the PCSP of Technology needs, use, supervision, and review;
•	Completion of an annual rights assessment process; and
•	Technology as a bridge to outcomes will be considered for all outcomes identified as not present during the annual Personal Outcome Measures.
The goal of this policy is promoting person-centered and person directed supports and thinking on all levels of the organization.

Assessment of needs

During the annual rights assessment planning process, the Enabling Technology Plan Questionnaire will be completed on all person supported by Buffalo River Services, Inc. For the purpose of identification of the persons priorities, interests and concerns, and the role and opportunities of technology in the person’s life.

•	Does the person have outcomes that could be achieved through technology, such as a desire for more independence?
•	Is the individual ready for the transition to use of technology?
•	Will enabling technology allow this person to achieve their vision of a preferred life?
•	Who in their life will be supportive or resistant to this transition?

HCBS Rules and Human Rights

The policy of Buffalo River Services, Inc. is Enabling Technology will not be used for the purpose of restricting rights or invading privacy. Enabling technology will only be used if it is agreed upon by the person supported for the purpose of promoting rights, independence and dignity.

PERSONS SUPPORTED USING TECHNOLOGY TO OBSERVE ACTIVITIES IN THEIR HOME

In the event that a person receiving supports requests to use technology, such as a closed- circuit camera system, to observe activities in their home, this use of technology will be discussed with the person and their COS. After a thorough discussion of how, why, and when, if the COS believes a legitimate need exists, the agency policy will be to support the technology.

USE OF TECHNOLOGY FOR EMPLOYMENT SERVICES SUPPORT

Buffalo River Services, Inc. recognizes the potential of technology to enhance employment outcomes. Enabling Technology training will be required for all job coach personnel. In addition, monthly job coach meetings will include a discussion of possible applications of technology in the workplace to enhance performance and/or reduce job coach support.

Outcomes and Goals
Technology outcomes and goals are always written to model independence and not as a means of monitoring the person supported.
Technology outcomes are proactive, support, teach skills, empower, allow dignity of risk, and introduce possibility.
Technology outcomes and goals are written to address the person’s preferences, concerns
and priorities of their life and not for any other purposes.

Self- Administration - Medication Administration using Technology

Refers to personally using prescription medication in a manner directed by the prescribing practitioner without assistance or direction. Intervention is limited to prompts using technology as to the time the medication is due.
•	Each self-administration program should be developed in accordance with the
individual’s needs and capabilities.
•	The circle of support and treating practitioner will evaluate and review the
individual’s functional and cognitive ability to self-administer medications.
•	All self-administration training will be coordinated with the person’s circle of support
and treating practitioner. The plan will include the following:
•	Individual training
•	Storage, labeling and documentation of administration
•	Oversight to ensure safe administration to include covering the 8 rights of medication administration
•	Ensure medication administration during any time the individual is incapable to include documentation

Use of Automated Medication DPCSPensers

Use of medication dPCSPensers must follow Tennessee Pharmacy rules and regulations. Any medication dPCSPenser used by Buffalo River Services, Inc. Must be sealed by the pharmacy and provide individual medication labels. The dPCSPenser must provide reasonable security for procurement and storage. Choice and type of medication dPCSPenser will be determined by the specific needs of the individual.

Technology Team

Buffalo River Services, Inc. will have a Technology Team that will consist of members of upper management (Executive Director, HR Coordinator, Director of Nursing, Vice President of Compliance, Chief of Operations) as well as representation from all levels of the agency (Team Leaders, Case Managers, Direct Support Professionals, Persons Supported). The point of contact for the Technology Team is the Program Coordinator.

Members of the Technology Team will include “Tech Champions”.	Tech Champions are people who are technologically savvy and committed to understanding the array and purposes of technology supports and who have a vision of how they can be best
used. Tech Champions will be responsible for specific areas of need. The Technology Team will be responsible for:
•	reviewing agencies policies and procedures as they relate to technology
•	assessing programming and empowering the priorities, preferences and goals of people supported
The Technology Team will present a report to the quarterly Person-Centered Organization meeting and seek input from internal and external stakeholders who attend this meeting.

Technology Vendors – Selection and Expectations

Vendors will be invited into the process after the COS has convened for person centered planning and outcomes have been identified.
The agency and person supported will seek to understand the standard operating procedure of the vendor and if these meet the vision of the agency, person and COS.
Expectations of Vendors include:
•	Compliance with all applicable laws
•	Align with agency person centered philosophy
•	Live support 24/7
•	Education and consultation
•	A description of what support looks like
•	Alerts going to the right person/place
•	Assistance during annual process
•	One-on-one support
•	Expertise on particular types of technology
•	Approved status by MCOS or DDA

Remote Support Plan

In addition to and in conjunction with an Independent Support Plan or Person Centered Support Plan a personal remote support plan will be developed by the agency and COS through the Facilitated PCP process for each person supported by technology. At a minimum, the plan will identify:
•	The intended outcome of the use of enabling technology;
•	The specific enabling technology being used and its purpose;
•	Facets of their life to be supported by enabling technology
•	Activities in which enabling remote supports are needed (e.g. cooking, working, community life, transportation, etc.);
•	Who the COS has selected to have access to content gathered via remote supports;
•	An Emergency Response Plan and Back-up System Response Plan;
•	
•	
•	A Program Supervisor will make a minimum of a weekly visit.

Back-Up Plan and On-Call Procedures

Given the 24/7 nature of programs, a formal on-call system is necessary to ensure the availability of back-up staff in various situations. Expectations related to on-call responsibilities are listed below.
The agency has an on-call policy, plan and roster which will be used.

Check and Maintenance of Technology

The agency will be responsible for assuring proper functioning of enabling technology equipment and timely replacement of equipment necessary for proper support. A person will be identified at each site and hold responsibility for checking technology weekly. A maintenance checklist will be used to document efforts. Batteries and other needed anticipated maintenance items will be kept on site to avoid delays in support. All technology failures of 15 minutes duration or more will be considered an emergency – refer to Back-Up Plan and On-Call Procedures below.
Responsibilities of Agency and Staff:
•	Test functioning;
•	Replace Batteries;
•	Respond to all alerts and notifications (even default notifications);
•	Develop a backup service plan for each person; and
•	Request changes in system and supports in a timely manner.

Follow Up and Documentation

The TIMAS electronic documentation system will be used to document all supports, events, reportable incidents, sick slips, falls, and behaviors.
•	A data review occurs bi-weekly at Technology Team meetings and if there are concerns, a COS is scheduled.

Education

An agency goal and focus will be educating all employees on the unlimited possibilities of technology to increase independence and a preferred life for people supported DSP’s who support individuals using technology supports and all members of the agency administration team will be required to complete standardized training requirements and specified curriculum identified by the DDA Enabling Technology Unit. The agency will also encourage and support all other stakeholders involved with an individual using technology to also complete the standardized training.

Educational opportunities will be identified and implemented for employees at all levels of the organization. Educational opportunities will include visiting sites where technology is being successfully used and becoming proficient on electronic devices, such as iPads and mobile apps. An enabling technology introduction will be added to New Hire training that includes examples of available technology. Focus groups will be held with people supported

to educate them on the possibilities of technology in their life. Periodically, focus groups will be held exclusively for people supported who are currently receiving technology supports to allow them a platform to compare and learn from each other. During monthly job coach meetings, identification and implementation of technology supports in the workplace will be a monthly agenda item.

Information Technology Policies

Buffalo River Services, Inc. utilizes electronic forms of communication, data collection, record management and evaluative measures in order to provide the highest possible level of support to individuals with intellectual disabilities. This policy is intended to safeguard and properly manage all records created, received, maintained, used, or stored on electronic media.

1.	Business Associate Agreement
Buffalo River Services, Inc. outsources IT support functions to AIT for maintenance, protection, storage and back up of electronic data. A Business Associate Agreement will be signed that outlines the terms, conditions and accepted operating procedures of this agreement.

2.	Use of Internet
Access to the Internet through the Buffalo River Services, Inc. network is a privilege and carries responsibilities reflecting responsible and ethical use and the stipulations of this policy. Use of the Internet through the Buffalo River Services, Inc. network constitutes the individual's acceptance of this policy. Employee-users are expected to be knowledgeable of these and all policies of Buffalo River Services, Inc. Care must be taken by all employee- users to ensure that accessing the Internet does not jeopardize Buffalo River Services, Inc. interests. Violations of this or any other Buffalo River Services, Inc. policy subjects the employee-user to immediate revocation of system privileges and may result in further disciplinary action, up to and including termination. (See Social Media policy and further Enabling Technology policy).

3.	Wireless and Mobile Device Acceptable Use Policy
With the growing demand for wireless technology, the following policy applies to all wireless networks and mobile devices used by Buffalo River Services, Inc. and its employees.

The only wireless and/or mobile devices to be used in conducting agency business will be agency owned devices. Personal cell phones and/or other mobile devices are strictly forbidden in the transfer of any agency and/or protected data. The expertise and guidance of AIT and/or Enabling Technology vendors will be utilized to assure that appropriate encryption mechanisms are available on all agency owned devices. The only exception to this policy is employee to supervisor communication that does not involve sensitive or protected information.

Addition of any new hardware, software, and/or related components to provide additional mobile device connectivity will be managed at the sole discretion of AIT in consultation with senior management and ET provider.

Buffalo River Services, Inc. employees using agency owned mobile devices and related software for network and data access will, without exception, use secure data management procedures. All mobile devices must be protected by a strong password. All users of mobile devices must employ reasonable physical security measures. Passwords and other confidential data as defined by Buffalo River Services, Inc.is not to be stored on mobile devices.

In the event of a loss or stolen mobile device it is incumbent on the Buffalo River Services, Inc. employee to report this to the Chief Executive Officer immediately. The device will be locked to prevent access by anyone other than authorized users.

AIT will establish audit trails and these will be accessed, published and used without
notice. Such trails will be able to track the attachment of an eternal device to a PC or other unauthorized access to protected networks.

Employees of Buffalo River Services, Inc. Are prohibited from accessing wireless networks with personally owned devices in the office or homes of people supported. AIT will guide agency management in assuring access points are protected from unauthorized intrusions. Employees who do not adhere to this policy may be subject to disciplinary action up to and including dismissal.

4.	Authentication Process
The employee-user must first be authenticated through a Buffalo River Services, Inc.- assigned network username and password. The username and password are the responsibility of the individual to whom it is assigned. Only the employee-user to whom the username and password are assigned may access the network with these codes. Violations of the Buffalo River Services, Inc. Electronic Records and Internet Use Policy and any other policy through the unauthorized use of the username and password subjects the individual to whom it is assigned to disciplinary action, up to and including termination. You should not expect that transmissions made through the Buffalo River Services, Inc. network are confidential. Although you will be given a username and password, this does not insulate transmissions from employer review.

5.	Safeguards and Remote Access
Buffalo River Services, Inc. runs all information services behind a firewall and remote systems are connected to the Buffalo River Services, Inc. network through a VPN connection. No person is allowed access to the Buffalo River Services, Inc.
system outside of the firewall. Antivirus software must be installed and maintained on all computers that are allowed access to the Buffalo River Services, Inc. system, including all incoming and outgoing electronic mail systems. In the case of off-site access, connection to the Buffalo River Services, Inc. network is only allowed via a VPN connection that will be configured by Buffalo River Services, Inc. No personally owned computers can be

connected to the Buffalo River Services, Inc. Network without prior approval from the Executive Director. All software installed on Buffalo River Services, Inc. computers must have a valid license registered to Buffalo River Services, Inc. Buffalo River Services, Inc. will utilize Microsoft Office software for word processing, spreadsheet and presentation programs. All computers will be installed with an approved version of the Microsoft Windows operating system. Any other software that is needed must have a valid license assigned to Buffalo River Services, Inc. Staff members are not permitted to download any software from the Internet without authorization from management. Employee-users will not have administrator privilege on Buffalo River Services, Inc. PCs.

Buffalo River Services, Inc. Staff must not attempt to gain access to any computer service or information for which they have not been granted access. Problems with the network or with a PC or any other request should be reported to Administration Director or to a user's supervisor. Buffalo River Services, Inc. Staff must not attempt to repair computer equipment.

6.	HIPAA/HITECH
Protected health information received, created or transmitted by the covered component shall not be shared with the non-covered component. The following provisions regarding HIPAA and HITECH apply to the Buffalo River Services, Inc. Program. Buffalo River Services, Inc. will comply with all Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health Act (HITECH) Regulations. As a result, employees will be required at a minimum to adhere to the following practices:
•	Take safeguards to ensure that PHI is protected at all times;
•	Ensure that all Protected Health Information (PHI) transmitted electronically is encrypted;
•	Report to Buffalo River Services, Inc. immediately upon becoming aware of any use or disclosure of PHI not authorized under HIPAA/HITECH policies.

7.	Electronic Mail Policy
Email is an agency resource and may be used solely for purposes that directly benefit Core Services. Email may not be used in violation of Federal or State laws, to distribute information that contradicts or is in violation of Buffalo River Services, Inc. Policies or to conduct personal business beyond what is reasonable and usual during the course of a business day. Email resources and files are agency property and must not be considered private. Management reserves the right to monitor email use and review the content of all messages and files on the email system.

8.	Personal Use
Limited personal use of the Internet is allowed by Buffalo River Services, Inc. However, the employee-user is reminded that use of any and all Buffalo River Services, Inc. property is primarily for the purpose of Buffalo River Services, Inc. business. Any personal use of the Internet is expected to be on the user's own time and is not to interfere with the person's job responsibilities. In addition, any posting to public forums such as newsgroups, or any transmittal of electronic mail through the Internet for personal use must include a disclaimer that the views are those of the employee-user and not Buffalo River Services,

Inc. These forums should be used with care and not cause any adverse publicity or embarrassment to Buffalo River Services, Inc. Downloading of streaming media for personal use from the Internet is prohibited. This includes listening to Internet radio and television broadcasts, watching online movies, and listening to music subscription services such as Napster and Yahoo music.

9.	Electronic Signature
Buffalo River Services, Inc. defines an electronic signature as a digitized identifier intended by the person using it to have the same force and effect as the use of a manual signature. This is accomplished by requiring a private username and password whenever an electronic document is digitally noted or signed. As electronic documents are verified by the composer a digital signature is attached to each document to authenticate the entry. Every digital signature is unique to the signer because every staff member is required to use their own username and password each time a digital signature is required. The username and password are known only by the staff member. Staff members are not allowed to divulge their usernames and passwords to any other person. Once signed, the system will not allow any modification to the original note. If the staff member recognizes an error or realizes that additions or modifications to the note are necessary, the staff member must log an addendum to the note and sign it separately.

10.	Ethical Use of Internet
At any time and without prior notice, Buffalo River Services, Inc. management reserves the right to examine email, personal file directories, and other information stored on Buffalo River Services, Inc. computers. This examination helps to ensure compliance with internal policies, supports the performance of internal investigations, and assists the management of information systems. As such, management may monitor access to the Internet. Use of the Internet constitutes acceptance of such monitoring. This policy should be read and interpreted in conjunction with all other Buffalo River Services, Inc. policies including but not limited to policies prohibiting harassment, discrimination, offensive conduct or inappropriate behavior. Employee-users are prohibited from accessing the Internet for any unethical purposes, including pornography, violence, gambling, racism, harassment, or any illegal activity. Employee-users are forbidden from using profanity or vulgarity when positing electronic mail via the Internet or posting to public forums (i.e., newsgroups). Any electronic mail sent through or postings to public newsgroups must fall within these ethical standards. The employee-user must abide by all federal and state laws with regard to information sent through the Internet. The Buffalo River Services, Inc. Code of Ethics strictly prohibits unauthorized release or disclosure of any individual or employee information through the Internet or through any other means. Company trade secrets and confidential information should not be transmitted over the Internet. Buffalo River Services, Inc. will comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) in the use of all electronic media. Every effort will be made to maintain appropriate administrative, technical and physical safeguards to protect the integrity, confidentiality, security, and availability of electronic records. Ongoing efforts will take place to prevent, detect, contain, and correct security violations. Employee-users are also prohibited from using Internet access through Buffalo River Services, Inc. systems for any other business or profit-making activities. In general, employees should exercise the same restraint and caution in drafting and transmitting messages over the Internet as they would when writing

a memorandum and should assume that their message will be saved and reviewed by someone other than the intended recipients. To obtain detailed information regarding the obligations and responsibilities of employee-users while communicating via e-mail please refer to Buffalo River Services, Inc.’s Electronic Mail Policy.

11.	Downloading Software
Employee-users are prohibited from downloading software from the Internet without prior written approval of management. Downloading of games from the Internet is prohibited. Downloading of any executable files or programs which change the configuration of your system by anyone other than Information Systems personnel is prohibited. The employee- user should take extreme caution when downloading software or files from the Internet. All files or software should be passed through virus protection programs prior to use. Failure to detect viruses could result in corruption or damage to files and/or unauthorized entry into Core Services of Northeast Tennessee’s network. It is mandatory that you comply with copyright and trademark laws when downloading material from the Internet. If the employee-user finds that any damage occurred as a result of downloading software or files, the incident should be reported immediately to management.

12.	Data Ownership
The agency information systems, data and computing assess are the property of Buffalo River Services, Inc. and are valuable agency property. All agency data and agency information systems are agency property. The Chief Executive Officer assumes oversight responsibilities for all information maintained on the network and other central systems while all other staff assume responsibility for data maintained on the individual work stations.

Critical information systems and their data should be stored using network backup
drives. Information stored on workstation drives is the direct responsibility of the individual using the workstation drive. Information stored, maintained or accessed on individual computers that is in violation of any state or federal laws, including but not limited to copyright laws, will be construed as a violation of these policies.

Agency data and agency information systems should only be used as authorized by senior management. Access to agency data and agency information systems should conform to an employee’s job function and/or description. Release of data should comply or in keeping with agency, person supported or funder confidentiality policies. Violations of this policy should be reported to the Executive Director.

13.	Use of Private End-Point Storage Devices
End-point storage devices, including USB sticks, thumb drives, flash drives, SD Cards, CDROMs, DVDs, Smartphones, Portable MP3 players or other removable data storage devices have the ability to cause potential damage to the confidentiality, integrity and availability of data within the Buffalo River Services, Inc. organization. As a result, the connection of privately-owned end-point storage devices to Buffalo River Services, Inc.’s computers are not permitted. Users are not permitted to circumvent or override any of the security measures in place for these devices.

14.	Staff Activities in Social Networking
Current employees and volunteers of Buffalo River Services, Inc. (including contract professionals, volunteers, consultants, administration and members of the board) will not reference, express or communicate their relationship, interaction and experiences with any individual (living or deceased) participating in services and supports provided by Buffalo River Services, Inc. on any social networking sites. Buffalo River Services, Inc. employees are prohibited from engaging in any personal social networking while on the clock at Buffalo River Services, Inc.
15.	Use of ENABLING TECHNOLOGY
On any location where Enabling Technology is used Buffalo River Services, Inc. will assure the following:
•	Access to a High-Speed Internet connection with enough bandwidth to support recommended enabling technology devices.
•	A central networking system using wired-connection, WI-FI gateway, Infrared, Blue Tooth, or cloud connectivity.	Buffalo River Services, Inc. management will work with the ET vendor and AIT to determine and acquire the most functional method possible,
•	Agency staff assigned to remote support of an individual will be provided with agency owned internet capable devices including computers, smartphones, or mobile tablets for the receipt and transfer of remote support data. Personally, owned devices will be prohibited in the transfer and/or receipt of remote support data and other company business data.
•	All agency owned internet capable devices will be managed through secured web- based and/or mobile interface that meets the information technology requirements explained in this policy.
•	All agency owned internet capable devices will have the ability to send and receive daily communication, notifications, and alerts through emails, texts, and/or video and phone conferencing.
•	Such devices and associated data collected will comply with the all Information Technology policies and procedures previously listed in this policy.
•	
V.		Buffalo River Services, Inc. MAPS Policies and Procedures

MAPS Project Management: Medicaid Alternative Pathways to Independence
MAPS Policies and procedures are guidelines to help managers and staff to create, run, and to provide successful services and supports in a coordinated and controlled way to provide proper quality assurance that MAPs services are delivered well.
These guidelines help to:
•	ensure that all project activities are completed within a specific time and cost framework;
•	ensure that the best practice is used whatever stage the project is at;
•	provide a framework for responding to both routine and unexpected issues;
•	enable those working on the project at all stages to adhere to relevant legislative and regulatory requirements; and
•	Provide assurances to the people and families receiving the services and supports of MAPS and the funding source.
We will follow the requirements as provided in this description of the MAPS program by DDA:
MAPs is a program that will set people living with intellectual and developmental disabilities on a path to learn skills to help them work, live independently, learn about their neighborhoods, and find hobbies that interest them. The services in this program will help persons supported effectively identify community interests and resources by building their own Virtual Community Resource Map (VCRM), assist in establishing true and meaningful community networks and develop independent living skills through supports such as technology-enhanced and smart home living skills, community transportation, peer mentoring, and an array of employment services.
Who is eligible for MAPs?
MAPs has funding to serve up to 1,250 people with intellectual and developmental disabilities either exiting the school system or who have recently exited and may be waiting for traditional waiver services.
What will the program provide?
The MAPs program will provide services that encourage sustainable independence and focus on:

•	Identifying people and places in their local communities that share like interests or align with their future goals;
•	Learning to harness the power of accessible and affordable technologies to foster their own functional independence;
•	How to navigate and travel independently in their community and how to build natural support networks; and
•	Independent living skills.
Participants will receive an annual cap of $20,000 for up to 3 years while enrolled in the program.
Enrollment for the MAPs program will focus on:
•	High school students during the three years leading up to their graduation, whether they are planning to graduate at 18 or 22.
•	Young adults who have recently left the school system.
•	People who are waiting for Employment and Community First CHOICES.

Buffalo River Services, Inc. will practice following our policies centered around service provision as we do for all our programs. We will operate with guidance to provide ethical and principled organizational performance in all that we do with a focus on employment, enabling technology, and person centeredness.

Saved as:
Documents: BRS, Inc. Program Services Handbook June 2023